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Deanna Posted Mon 27th of November, 2017 20:25:02 PM
10 year old patient is given influenza, Gardasil and meningitis vaccines IM. The documentation reads “Immunization counseling provided.” Due to the lack of documentation should I use 90471 and 90472 for the administration codes? What are the documentation requirements for immunization administration counseling and component billing?
SuperCoder Answered Tue 28th of November, 2017 00:59:47 AM


There is a golden rule of medical coding "what is not documented is always considered not done." In order to bill immunization administration, there has to be proper documentation. In order to bill for counselling, documentation usually requires a brief summary of what was discussed (A face-to-face discussion is performed by the physician/other qualified healthcare professional with the patient or caregiver. Typical items reviewed as part of the counseling are risks and benefits of vaccination, patient/care giver concerns, signs and symptoms of adverse effects, and when to seek medical attention for any adverse effects). Also there is vaccine information sheet and consent form that the parent/guardian must sign that states they were counseled on the vaccine(s) It also lists the vaccine(s) that were counseled with parent/guardian signature as well as the provider signature.

CPT code 90460 and 90461: To correctly report vaccine counseling and administration with these codes, it is important to recognize what the codes do and do not include.

  • These codes are limited to immunization administration, meaning purchased vaccine products must be separately reported.
  • A face-to-face service where a physician or other qualified health care professional (qualified per state licensure) provides counseling to the patient and/or caregivers is required to report 90460-90461.
  • In the absence of counseling, the administrations must be reported with codes 90471-90474.
  • 90460-90461 are reported for administration to patients 18 years of age and under.
  • Code 90460 is reported for each separate administration of single component vaccines and/or first component of a combination vaccine.
  • When reporting administration of combination vaccines, code 90460 is reported for the first component and add-on code 90461 is reported for each additional component (no modifier -51 required).
  • Note that route of administration (whether injection, oral, or intranasal) does not matter, since the codes include “via any route of administration.”

CPT CODES 90471-90474:    Report codes 90471-90474 for immunization administration of any vaccine that is not accompanied by face-to-face physician or other qualified health care professional counseling the patient and/or family, or for patients over 18 years of age.

You may also refer to following link for further help:


Deanna Posted Sat 02nd of December, 2017 14:54:25 PM
Thanks so much! One more question regarding this: A signed consent is scanned into the EMR that states most that is listed above: "I have read the information pertaining to the ordered vaccine and have had an opportunity to ask questions. I understand the risk of an allergic reaction and/or side effects. I have reviewed the suggestions that indicate I should avoid taking the vaccine and I have also been offered further physician conference prior to receiving the vaccine. I agree that I do not meet the suggested avoidance criteria." BUT the documentation from the EMR encounter only states "immunization counseling provided". I do feel the single statement from the EMR encounter would not be enough by itself, but do you think the signed consent that is scanned would justify using the immunization counseling code? It seems to cover everything mentioned in your answer.
SuperCoder Answered Mon 04th of December, 2017 01:31:50 AM


This is not the appropriate documentation. This is just a consent form signed by the patient which cannot be considered appropriate in order to get paid for the services rendered by the physician. There has to have proper documentation that should be provided by the physician stating what services he has performed.


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