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Provider Manual

 

 

Billing for vaccines

Also see:

Billing for vaccine administration services

  • Only one initial administration code can be reported per day, regardless of vaccine administration method.
  • CPT codes 90460 (18 yrs and younger), 90471 and 90473 are initial administration codes and cannot be billed together on the same date of service.
  • When one of these initial administration codes is billed, report all additional vaccine/toxoid components administered with the appropriate add-on code (i.e. 90416, 90468, 90472 or 90474). Reference your CPT book for coding guidelines if you have additional questions.
  • When billing for multiple vaccine administrations, you can either report administration add-on codes per line or report as multiple units on one line.

Vaccine codes and medical coverage by plan

  • Self-funded plan coverage may vary by employer group.
  • Coinsurance may apply.
  • Routine vaccines listed as NOT COVERED under Medicare may be covered under Medicare Part D pharmacy benefit.
  • All covered vaccines are considered preventive. Deductible, if applicable, will be waived for InNetwork providers. For self-funded plans, a dollar limit may apply to preventive services. Check individual plan benefits.
  • VFC = Covered, BUT you must use the VFC program for members under 19 years of age
  • VFC only = Not covered for adult Medicaid members
  • # = Coverage of these vaccines will be evaluated once FDA approval granted

CodeDescriptionHMO/EPO,
POS, PPO,
MiChild		MedicaidMedicare
Advantage plans
90476 Adenovirus vaccine, type 4, live, for oral use NOT COVERED NOT COVERED NOT COVERED
90477 Adenovirus vaccine, type 7, live, for oral use NOT COVERED NOT COVERED NOT COVERED
90581 Anthrax vaccine, for subcutaneous use NOT COVERED NOT COVERED NOT COVERED
90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use Covered NOT COVERED NOT COVERED
90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use Covered NOT COVERED NOT COVERED
90632
 Hepatitis A vaccine, adult dosage, for intramuscular use Covered VFC NOT COVERED
Medicare Part B - covered only with diagnosis code of V01.79, contact with/or exposure to communicable diseases; other viral diseases
90633 Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use Covered VFC only NOT COVERED
Medicare Part B - covered only with diagnosis code of V01.79, contact with/or exposure to communicable diseases; other viral diseases
90634

Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for intramuscular use Covered NOT COVERED NOT COVERED
Medicare Part B - covered only with diagnosis code of V01.79, contact with/or exposure to communicable diseases; other viral diseases
90636 Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use Covered Covered NOT COVERED
90644
#		 Meningococcal conjugate vaccine,
serogroups C & Y and Hemophilus influenza b vaccine, tetanus toxoid conjugate (Hib-MenCY-TT), 4 dose schedule, when administered to children 2-15 months of age, for intramuscular use		 NOT COVERED NOT COVERED NOT COVERED
90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use Covered VFC only NOT COVERED
CodeDescriptionHMO/EPO,
POS, PPO,
MiChild		   Medicaid   Medicare
Advantage plans
90646 Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use Covered NOT COVERED NOT COVERED
90647 Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use Covered VFC only NOT COVERED
90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use Covered VFC only NOT COVERED
906492

Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use (Gardasil), ages 9-26 only Covered VFC NOT COVERED
90650 Human Papillomavirus (HPV) vaccine, types 16 and 18, bivalent, 3 dose schedue, for intramuscular use (Cervarix), ages 9-26 only, female only Covered VFC NOT COVERED
906541 Influenza virus vaccine, split virus, preservative free, for intradermal use NOT COVERED NOT COVERED Covered
90655 Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use Covered VFC only Covered
90656 Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use Covered VFC Covered
90657 Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use Covered VFC only Covered
90658 Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use Covered VFC NOT COVERED
(see Q codes)
90660 Influenza virus vaccine, live, for intranasal use, ages 2-49 only Covered VFC Covered
90661
#		 Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use NOT COVERED NOT COVERED NOT COVERED
90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use, ages 65+ only Covered Covered Covered
90664
#		 Influenza virus vaccine, pandemic formulation, live, for intranasal use NOT COVERED NOT COVERED NOT COVERED
90665 Lyme disease vaccine, adult dosage, for intramuscular use NOT COVERED NOT COVERED NOT COVERED
90666
#		 Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use NOT COVERED NOT COVERED NOT COVERED
90667
#		 Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use NOT COVERED NOT COVERED NOT COVERED
90668
#		 Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use NOT COVERED NOT COVERED NOT COVERED
CodeDescriptionHMO/EPO,
POS, PPO,
MiChild		   Medicaid   Medicare
Advantage plans
Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (AFLURIA) Covered VFC only Covered
Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLULAVAL) Covered VFC only Covered
Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLUVIRIN) Covered VFC only Covered
Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) Covered VFC only Covered
Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified) Covered VFC only Covered
90669 Pneumococcal conjugate vaccine, 7 valent, for intramuscular use, ages 0-10 years only Covered VFC only
 NOT COVERED
90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use, ages 0-5 years only Covered
VFC only NOT COVERED
90675 Rabies vaccine, for intramuscular use Covered Covered NOT COVERED
Medicare Part B - covered only with diagnosis code of V01.5, contact with/or exposure to disease; rabies
90676 Rabies vaccine, for intradermal use Covered Covered NOT COVERED
Medicare Part B - covered only with diagnosis code of V01.5, contact with/or exposure to disease; rabies
90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use, ages 6 weeks-8 months only Covered VFC only NOT COVERED
90681 Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use, ages 6 weeks-8 months only
Covered VFC only
NOT COVERED
90690 Typhoid vaccine, live, oral NOT COVERED NOT COVERED NOT COVERED
90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use NOT COVERED NOT COVERED
NOT COVERED
90692 Typhoid vaccine, heat- and phenol-inactivated (H-P), for subcutaneous or intradermal use NOT COVERED NOT COVERED NOT COVERED
90693 Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (U.S. military) NOT COVERED NOT COVERED NOT COVERED
90696 Diphtheria, tetanus toxoids, acellular pertussis and poliovirus vaccine, inactivated (DTaP - IPV) when administered to children 4-6 years of age, for intramuscular use Covered VFC only NOT COVERED
90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP - Hib - IPV), for intramuscular use Covered VFC only
NOT COVERED
90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for use in individuals younger than 7 years, for intramuscular use Covered VFC only NOT COVERED
CodeDescriptionHMO/EPO,
POS, PPO,
MiChild		   Medicaid   Medicare
Advantage plans
90701 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use Covered NOT COVERED NOT COVERED
90702 Diphtheria and tetanus toxoids (DT) adsorbed for use in individuals younger than 7 years, for intramuscular use Covered VFC only NOT COVERED
Medicare Part B - covered only with diagnoses codes:
  • 870.0-897.7, Open wound, traumatic amputation
  • 910.00-919.9, Superficial injury
  • V03.7, Tetanus toxoid alone
90703 Tetanus toxoid adsorbed, for intramuscular use Covered NOT COVERED NOT COVERED
Medicare Part B - covered only with diagnoses codes:
  • 870.0-897.7, Open wound, traumatic amputation
  • 910.00-919.9, Superficial injury
  • V03.7, Tetanus toxoid alone
90704 Mumps virus vaccine, live, for subcutaneous use Covered Covered NOT COVERED
90705 Measles virus vaccine, live, for subcutaneous use Covered Covered NOT COVERED
90706 Rubella virus vaccine, live, for subcutaneous use Covered Covered NOT COVERED
90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use Covered VFC NOT COVERED
90708 Measles and rubella virus vaccine, live, for subcutaneous use Covered Covered NOT COVERED
90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use Covered VFC only NOT COVERED
90712 Poliovirus vaccine, (any type(s)) (OPV), live, for oral use Covered NOT COVERED NOT COVERED
CodeDescriptionHMO/EPO,
POS, PPO,
MiChild		   Medicaid   Medicare
Advantage plans
90713 Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use Covered VFC NOT COVERED
90714 Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in individuals 7 years or older, for intramuscular use Covered VFC NOT COVERED
Medicare Part B - covered only with diagnoses codes: 
  • 870.0-897.7, Open wound, traumatic amputation
  • 910.00-919.9 Superficial injury
  • V03.7 Tetanus toxoid alone
90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for use in individuals 7 years or older, for intramuscular use Covered VFC NOT COVERED
Medicare Part B - covered only with diagnoses codes: 
  • 870.0-897.7, Open wound, traumatic amputation
  • 910.00-919.9 Superficial injury
  • V03.7 Tetanus toxoid alone
90716 Varicella virus vaccine, live, for subcutaneous use Covered VFC NOT COVERED
90717 Yellow fever vaccine, live, for subcutaneous use NOT COVERED NOT COVERED NOT COVERED
90718 Tetanus and diphtheria toxoids (Td) adsorbed for use in individuals 7 years or older, for intramuscular use Covered Covered NOT COVERED
Medicare Part B - covered only with diagnoses codes: 
  • 870.0-897.7, Open wound, traumatic amputation
  • 910.00-919.9 Superficial injury
  • V03.7 Tetanus toxoid alone
90719 Diphtheria toxoid, for intramuscular use Covered NOT COVERED NOT COVERED
90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for intramuscular use Covered NOT COVERED NOT COVERED
90721 Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use Covered VFC only
NOT COVERED
90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use Covered VFC only NOT COVERED
CodeDescriptionHMO/EPO,
POS, PPO,
MiChild		   Medicaid   Medicare
Advantage plans
90725 Cholera vaccine for injectable use NOT COVERED NOT COVERED NOT COVERED
90727 Plague vaccine, for intramuscular use NOT COVERED NOT COVERED NOT COVERED
90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use Covered VFC Covered
90733 Meningococcal polysaccharide vaccine (any groups), for subcutaneous use Covered Covered NOT COVERED
90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use Covered VFC NOT COVERED
90735 Japanese encephalitis virus vaccine, for subcutaneous use NOT COVERED NOT COVERED NOT COVERED
907362 Zoster (shingles) vaccine, live, for subcutaneous injection
Ages 60+ only		 Covered Covered NOT COVERED
90738 Japanese encephalitis virus vaccine, inactivated, for intramuscular use NOT COVERED NOT COVERED NOT COVERED
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use Covered Covered Covered
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use Covered NOT COVERED Covered
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use Covered VFC Covered
CodeDescriptionHMO/EPO,
POS, PPO,
MiChild		   Medicaid   Medicare
Advantage plans
90746 Hepatitis B vaccine, adult dosage, for intramuscular use Covered VFC Covered
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use Covered VFC Covered
90748 Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use Covered VFC only NOT COVERED
90749 Unlisted vaccine/toxoid Covered Explanatory notes must accompany claim Covered
Explanatory notes must accompany claim		 NOT COVERED

1Intradermal Fluzone (code 90654) will not be covered for Priority Health members for the 2011 – 2012 influenza season due to the number of alternative products available.

2At this time Zostavax (90736) is covered for members 60 and older only, absent a recommendation to reduce the age by ACIP.

Last modified: 1/5/2012
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