CPT 90473

North Carolina Medicaid – Billing Guidelines for Vaccines


1. Effective with date of service July 1, 2011, the ONLY immunization administration codes covered for Medicaid recipients in the Health Check age range, 0 through 20 years of age, are CPT 90471 through CPT 90474.

2. Claims billed with CPT immunization administration codes CPT 90460 and CPT 90461 (effective for dates of service on and after January 1, 2011, for Medicaid recipients through 18 years of age) on and after July 1, 2011, will deny.


3. Append modifier EP to all immunization administration codes billed for Medicaid recipients in the Health Check age range, 0 through 20 years of age.

4. Do NOT append the EP modifier to the vaccine CPT codes.

5. All of the units billed for codes CPT 90471EP, CPT 90472EP, CPT 90473EP, and CPT 90474EP must be billed on ONE detail to avoid duplicate audit denials. Currently, CPT 90474EP cannot be billed with CPT 90473EP because there are no two oral/intranasal vaccines that would be given to a recipient. Only one unit of either CPT 90473EP or CPT 90474EP is allowed.

6. CPT vaccine codes for the vaccines administered must be reported or billed, as appropriate, even if administration codes are not being billed.

7. For Medicaid recipients 21 years of age and older (above the Health Check age range), the immunization administration codes have not changed. Bill the series of codes CPT 90471 through CPT 90474 without the EP modifier.

Please refer to individual bulletin articles on specific vaccines for additional billing guidelines.

Please visit North Carolina Medicaid Coverage for Preventive examination and Screening services.

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