Immunization services can be one of the most challenging to bill. Not because of the operational difficulties, but due to minor details that lead to claim denials. Among the most used immunization codes is CPT code 90460.
We have created this guide to simplify this code for you. By the end of this guide, you will have all the necessary information required to file this code successfully. So, let’s start.
CPT Code 90460 – Description
CPT code 90460 is defined as:
“Immunization administration through 18 years of age via any route of administration, with counseling by a physician or other qualified healthcare professional; first or only component of each vaccine or toxoid administered.”
As evident from the definition, CPT code 90460 is an immunization code. It is used for patients who are 18 years of age or younger. It is a foundational pediatric vaccination code, and one of the most used codes in pediatric practices.
What’s important to note here is that this code covers the administration of the first or only component of each vaccine administered during a single visit. Never use it for subsequent vaccinations. Otherwise, be prepared to face a denied claim.
Additionally, don’t get confused by the method of administration. For 90460, the route of vaccine administration is irrelevant. You can use code 90460 for any route, such as percutaneous, intradermal, subcutaneous, intramuscular, intravenous, intranasal, or oral. Plus, for 90460 to be valid, counseling by a physician or qualified healthcare professional is essential.
When dealing with combination vaccines that contain multiple components (antigens), use CPT code 90461 for each additional vaccine or antigen.
Scenarios Where CPT Code 90460 is Applicable
How do you determine when to use CPT code 90460 versus other vaccine administration codes? By knowing exactly when you can use this code. The following are some scenarios in which you can use code 90460:
Combination Vaccines
We have already discussed that you can use CPT code 90460 for billing only when one vaccine is to be administered. However, things get a bit trickier when multiple vaccines are involved. Here’s how you can use 90460 in conjunction with other subsequent vaccines:
- DTaP vaccine (3 components): Report 90460 x 1 unit, 90461 x 2 units
- MMR vaccine (3 components): Report 90460 x 1 unit, 90461 x 2 units
- DTaP-Hib-IPV vaccine (5 components): Report 90460 x 1 unit, 90461 x 4 units
VFC Program Vaccines
In pediatric practices, the Vaccines for Children (VFC) program is a crucial part. It is a federally funded program under which important vaccines are provided by the government at no cost. This program is targeted towards eligible children under 19 years of age, including those who are uninsured, Medicaid-eligible/enrolled, underinsured, or American Indian/Alaska Native.
However, to receive the reimbursement from the government, practices must enroll in the VFC program. While the vaccine products are provided free of charge, providers can bill for the administration services using CPT code 90460.
Applicable Modifiers for CPT Code 90460
The following are some modifiers that you can use when billing with CPT code 90460:
| Modifier | Description | When to Use |
|---|---|---|
| 59 | Distinct Procedural Service | To indicate that vaccine administration is separate from other services rendered on the same day to the same patient by the same provider. |
| SL | State-supplied vaccine | When a vaccine product is provided at no cost by state programs. Note that this modifier is appended to the vaccine product code, not the administration code. |
CPT Code 90460 – Billing & Reimbursement Guidelines
The following are some important points to keep in mind while filing claims for CPT code 90460:
Provide Detailed Documentation
Comprehensive documentation is crucial for avoiding claim denials. You must include the following details in your CPT code 90460 claims:
- Patient’s age verification (must be 18 years or younger)
- Face-to-face counseling details with the parent/guardian
- Specific vaccine components administered
- Vaccine Information Statement (VIS) provided to parent/guardian
- The date on which counseling was provided
- Provider credentials and signature
Check the Medicare Reimbursement Rate
The reimbursement amount for CPT code 90460 varies for each MAC locality. However, Medicare has set its national average reimbursement amount at $22.32 for non-facility settings.
You can check the reimbursement rate for your MAC locality via the PFS Lookup Tool.
Wrapping Up
CPT code 90460 is a simple yet essential immunization code. Missing out on small details when filing insurance claims for 90460 may lead to denials. We hope that by following the tips and tricks mentioned in this guide, you will be able to receive fair reimbursement for your services.
If you are experiencing frequent denials or bottlenecks in your billing operations, consider contacting our billing specialist at MediBillMD. We offer premium pediatric billing services at competitive rates.
