(2023) 90686 CPT Code | Description, Guidelines, Reimbursement, Modifiers & Examples

90686 CPT code may be used for service when the physician administers influenza virus vaccine, quadrivalent IIV4), split virus, preservative-free, 0.5 ml dosage for intramuscular use. A flu vaccine solution injects into the patient and can also give as a nasal spray.  

Description Of The 90686 CPT Code  

90686 CPT code reports for the use of vaccines only. A vaccine produces active immunization by inducing the immune system to build antibodies against specific microorganisms/viruses.  

Report 90682 for an antibiotic- and preservative-free, quadrivalent (RIV4) influenza vaccine derived from recombinant DNA and hemagglutinin (HA) protein. 

A split virus suspension of four (two influenza A and two influenza B) (IIV4) of the most prevalent strains of influenza prepares for intramuscular injection. The human body remembers the antibody production pattern for long-term immunization.  

Report 90685 for a preservative-free, split virus influenza vaccine dose of 0.25 mL and 90686 CPT code for 0.5 mL. Report 90687 for a divided virus influenza vaccine dose of 0.25 mL not preservative-free and 90688 for 0.5 mL.

Report 90689 for a preservative-free, inactivated, and adjuvanted quadrivalent influenza vaccine dose of 0.25 mL. Report these codes with the appropriate administration code. 

The official description of the 90686 CPT code is: “Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use.”

Reimbursement 

A maximum of one unit can be a bill on the same service date of CPT code 90686. In contrast, the two units allow when documentation supports the medical necessity of the service.  

The cost and RUVS of 90686 CPT code are $20.526 and 0 when performed in the facility. In contrast, the reimbursement and RUVS of 90686 are $20.526 and 0 when performed in the non-facility. 

Medicare requires HCPCS code G0008 for the administration. Medicare waives this code’s Part B deductible, coinsurance, or copayment when all other requirements meet the standards.

This service is covered by Medicare once per influenza period. Medicare may cover additional seasonal influenza virus vaccinations when medically necessary. 

Billing Guidelines 

Documentation should indicate the specific vaccine, route of administration, dosage, and any adverse reactions experienced by the patient, if applicable. A notation of how long the patient remained in the office after vaccine administration should also be documented.

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.   

 The following are ICD category 10 Payable Dx codes when 90686 CPT code bills: Z23, Z29.8. 

90686 covers vaccines only; report the administration code separately from the 90686 CPT code. 

Separately identifiable E/M benefits may report in addition to the vaccine and toxoid administration codes. Report this code with the appropriate administration code. 

Administration codes should only say when the clinician renders face-to-face counseling to the patient or family when the immunization administers. 

For administration of a vaccine without the face-to-face clinician counseling service for patients 18 years of age and older, see 90471–90474.

Immune globulins and administration (90281-90399, 96365-96375) report separately with code 90686. It is appropriate to report combination vaccine components individually. 

Report CPT code 90686 in addition with Administration vaccine CPT Codes (90460-90461,0001A, 0002A, 0013A, 0021A, 0022A, 0031A 90471-904740003A, 0004A, 0011A, 0012A, [0034A], [0041A, 0042A], 0051A, 0052A, 0053A, 0054A, [0064A], 0071A, 0072A, 0073A, 0081A-0082A, 0094A.

90686 includes Afluria Quadrivalent, Fluarix Quadrivalent, Flulaval Quadrivalent, and Fluzone Quadrivalent.

The flu shots recommend by the CDC every six months, and the date is beyond October during the flu season.

Patients can take flu shots twice a year, and it is reimbursable. One flu shot covered by medicare part b claims every six months. They may cover additional flu shots if documentation supports the medical necessity.

90686 CPT code includes age parameters for reporting purposes only. It does not pertain to the product’s license. 

Billing Examples

A 60-year-old male with no medical history now presents for an annual wellness visit and immunization in the hospital outpatient setting. The patient has seasonal allergies every season. He recommends by his primary care provider to have flu shots every season. 

The patient denies headache, blurry vision, itching, dryness,  dizziness, chest pain, shortness of breath, motor weakness, numbness/tingling, abdominal pain, nausea/vomiting, and urinary bladder issues.

Physicians provide the necessary counseling to the patient and the benefits of preventive measures. The physician ordered routine diagnostic labs and radiology tests. He suggested the flu shot vaccine every six months and scheduled an appointment for next week. 

Diagnostic studies show no significant abnormal findings during the exam and recommend flu shots twice a year.