CPT code 90471: Immunization administration

What is CPT code 90471?

CPT code 90471 is a medical procedural code established by the American Medical Association for reporting the administration of a single vaccine. This vaccine administration code is used when a provider gives an immunization—whether intramuscular, subcutaneous, oral, or intranasal—without additional evaluation and management services (E/M) billed on the same date. It is commonly used for routine vaccines, such as the appropriate flu vaccine (e.g., influenza vaccine administration), tetanus, hepatitis, and pneumococcal immunizations.

The code specifically applies when only one vaccine administration is performed. If combination vaccines or multiple vaccine components are given, proper coding is necessary to reflect each administration correctly. To correctly report vaccine counseling and administration, healthcare professionals must include relevant product codes and documentation.

CPT code 90471 documentation requirements

To support proper billing and compliance, documentation must demonstrate that the vaccine was administered according to clinical and regulatory standards. Required elements include:

• Vaccine name and manufacturer: Clearly record the full name of the vaccine (e.g., Influenza Quadrivalent 2024–2025) and the manufacturer (e.g., Sanofi, GSK). This is essential for traceability, especially in case of recalls or adverse events.
• Lot number and expiry date: Document the vaccine product's exact lot number and expiry date to meet CDC, FDA, and VFC documentation standards. This helps ensure product validity and enhances pharmacovigilance.
• Route and site of administration: Specify how and where the vaccine was administered, e.g., intramuscular injection in the left deltoid, subcutaneous injection in the right thigh, or oral drops. Avoid generic entries; be as specific as possible (e.g., left index finger for certain intradermal vaccines, if applicable).
• Patient’s consent: Document verbal or written consent from the patient or guardian. This is a legal requirement and ensures that the patient is informed about the vaccine's benefits and potential side effects.
• Adverse reactions (if any): Note any immediate or delayed side effects, such as redness, swelling, or fainting. If none were observed, it's best practice to document “no adverse reactions observed.”
• Vaccine counseling (when applicable): If the provider offered education on the vaccine, including benefits, risks, and aftercare, this should be documented. This may support using certain modifiers or justify separate billing of an E/M service when appropriate.

CPT code 90471 billing guidelines

Accurate coding is essential for correct reimbursement and to avoid claim denials. Keep these billing considerations in mind:

• Use 90471 for the first vaccine administration only: This code represents the initial vaccine administered during a patient encounter. It cannot be used more than once per visit.
• Report 90472 for each additional vaccine: If more than one vaccine is administered during the same visit, use CPT 90472 for the second and subsequent injections or doses. Each additional administration requires a separate line item on the claim.
• Bill the vaccine product separately using appropriate codes: Vaccine product codes (e.g., 90658 for influenza) must be listed separately from the administration code. Do not assume 90471 includes the cost of the vaccine itself—it only covers the service of giving the shot.
• Include a diagnosis code for immunization encounters: Common codes include ICD-10 Z23 (encounter for immunization), which supports medical necessity for most routine vaccines. Additional ICD-10 codes may be required for travel-related or occupational vaccines.
• Add National Drug Codes (NDCs) when required: Many payers—especially Medicaid—require NDCs alongside the CPT code to track vaccine usage at the national level. Include the NDC in an 11-digit format with proper labeling (e.g., 00006-4047-20).
• Follow special rules for pediatric and VFC program vaccines: If billing for pediatric immunization administration under the Vaccines for Children (VFC) program, ensure the claim clearly indicates VFC eligibility status and includes all required modifiers.
• Modifier 25 for same-day E/M services: If a separate evaluation and management service (e.g., a sick visit) is provided during the same encounter as the vaccination, report it with modifier -25 to distinguish it from the vaccine administration.
• Do not double-bill for combination vaccines: Some vaccines include multiple components (e.g., MMR or DTaP-HepB-IPV). Report a single administration code for the combination vaccine, not one per antigen.

Other relevant CPT codes

• 90472: Administration of each additional vaccine
• 90658: Influenza vaccine, quadrivalent