- Based on National Correct Coding Initiative (NCCI), reimbursement of both the evaluation and management (E&M) service and the immunization administration is contingent upon the provider reporting the modifier 25. Modifier 25 is used to identify a significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service. Documentation to substantiate the use of the modifier should be in the member's medical record and available for review if requested.
- When an administration of a vaccine Healthcare Common Procedural Coding System (HCPCS) code (G0008, G0009, G0010) is reported by the same physician or other qualified health care professional on the same day of an immunization administration Current Procedural Terminology (CPT) code (90460, 90461, 90471, 90472, 90473, 90474), the appropriate modifier should be applied to indicate that separate and distinct immunizations were administered.
- Professional providers are eligible to receive separate reimbursement for each component of multiple-antigen immunizations for patients 18 years of age or younger when the professional provider counsels the patient regarding the immunization during the visit in which the immunization is administered.
In this instance, professional providers should report CPT code 90460 for the first component of each immunization administered. CPT code 90461 should be reported in addition to 90460 for each additional component of a multiple-antigen immunization.
For example, to report the administration of the MMRV and DTaP immunizations with counseling to a patient 18 years of age or younger, professional providers should report:
- Codes 90460, 90461, 90461, 90461 for the MMRV immunization
- Codes 90460, 90461, 90461 for the DTaP immunization
- To report the administration of a single-antigen or multiple-antigen immunization for pediatric or adult patients without counseling, professional providers should report CPT codes 90471 or 90473 for the first immunization, and 90472 or 90474 for each additional immunization.
For example, to report the intradermal administration of the MMRV and DTaP immunizations to a patient without counseling, professional providers should report:
- Code 90471 for the MMRV immunization
- Code 90472 for the DTaP immunization
Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.