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Clarification for Billing Pediatric Immunization Administration CPT Codes 90460 and 90461

Blue Cross and Blue Shield of North Carolina (BCBSNC) would like to provide clarification for our network of healthcare providers billing the new immunization Current Procedural Terminology (CPT) codes 90460 and 90461. CPT codes 90460 and 90461 became effective January 1, 2011.

Clarification for appropriate filing of CPT codes 90460 and 90641 is not due to any change in BCBSNC processes. The instructions are being offered to facilitate payment and reduce claim denials as duplicates, healthcare professionals submitting claims to BCBSNC for immunization administration using codes 90460 and 90461 for multiple vaccines and/or multiple components, must report the code(s) in units and not per line item. By submitting per line item, claims are unable to be adjudicated appropriately. Please see below for additional clarification:

Definition

90460 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component

90461 (add on code) - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component (list separately in addition to code for primary procedure)

Billing Requirements

CPT codes 90460 and 90461 require each component of a vaccine to be reported separately. CPT defines a component as all antigens in a vaccine that prevents disease(s) caused by one organism. Combination vaccines are those vaccines that contain multiple vaccine components.

  • Use code 90460 to report the first (or only) vaccine/toxoid component of each vaccine.
  • Use code 90461 to report each additional component of that particular vaccine.

Codes 90460 or 90461 should not be listed on a claim more than once. Repeated administration code(s) will deny as duplicate services.

Example

An 18 year patient is counseled on risks and benefits of Pneumococcal Vaccine, Diptheria- Tetanus- Pertussis-Hepatitus B, Poliovirus Vaccine and seasonal influenza. The healthcare provider administers each vaccine, completes chart documentation and vaccine registry entries, and verifies there is no immediate adverse reaction.

Vaccine Code Descriptor Number of components Administration code
90670 Pneumococcal Conjugate Vaccine 1 90460 x1
90723 Diptheria, Tetanus Toxoids, Acellular Pertussis, Hepatitus B, Poliovirus Vaccine 5 90460 x1
90461 x4
90658 Influenza Virus Vaccine 1 90460 x 1

DO NOT repeat codes 90460 and 90461 on separate lines with the units split among those lines - three lines of 90460, four lines of 90461. Remember, when codes 90460 and 90461 are repeated on separate lines, line items will deny as duplicates!

DO list multiple units for each code to receive proper reimbursement. Multiple units for each code should reflect:

  • 90460 x 3 units - The 3 units represent the only component for pneumococcal and influenza vaccine and first component for DtaP-HepB-IPV
  • 90461 x 4 units - The 4 units represent each additional component of DtaP-HepB-IPV; no other vaccine has more than one component to report.

      

As a final reminder, healthcare providers should not submit multiple claims for the same encounter, as this may cause the claim to be rejected as a duplicate.