90686 cpt code

(2022) 90686 CPT Code Description, Guidelines, Reimbursement, Modifiers & Examples

90686 CPT code bills 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.  

90686 CPT Code Descriptions 

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 a 0.5 mL. Report 90687 for a divided virus influenza vaccine dose of 0.25 mL that is not preservative-free and 90688 for a 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. 

CPT 90686 bills for service when the physician administers the influenza virus vaccine, which includes:

(quadrivalent IIV4), split virus, preservative-free, and 0.5ml dosage for intramuscular use. 

cpt code 90686

90686 CPT Code 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 the Part B deductible, coinsurance, or copayment for this code 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. 

90686 CPT Code 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 administration of the vaccine should also document.

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, reporting the administration code separately with 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 and 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 in combination 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 seasons.

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. 

90686 cpt code description

90686 CPT Code Modifiers  

The following are the list modifiers applicable with CPT code 90686: 

22, 23, 47, 51, 52, 53, 58, 59, 76, 77, 78, 79, 99, AI, AQ, AR, CC, CR, ET, EY, GA, GC, GK, GR, GU, GY, GZ, KX, Q5, Q6, QJ, SG, TC, XR, XP, XU, XS. 

Modifier 76 is applicable with 90686 when a similar service performs by the Same Physician on the same service date. 

Modifier 76 is applicable with 90686 when a similar service performs by a different Physician on the same service date. 

Modifier 59 is applicable with 90686 CPT code when a Distinct service performs by the physician and bundled with another procedure on the same date.   

Modifier X {E, P, S, U} is applicable instead of Modifier 59 with CPT 90686  when service bills to medicare insurance. It divides the modifier into four parts for further specification of the procedure. 

Modifier 53 will be reported with CPT 90686  if an unsuccessful stress test occurs due to unavoidable circumstances like allergic reactions to the substance. 

Modifier 22 applies to CPT 90686 when services perform longer than usual and take extra resources during the procedure. 

Modifier 23 is applicable with 90686 when general or local anesthesia administers by the physician and routinely does not require during the procedure. 

Modifier 52 applies when the physician does not complete the immunization service and terminates due to unavoidable circumstances. 

If physicians believe that Medicare will deny such service, reporting with a GA modifier is appropriate. The beneficiary must sign an Advance Beneficiary Notification (ABN), and 90686 CPT code must apply the GA modifier to that service. 

90686

90686 CPT Code Examples

The following are the examples when CPT code 90686 bills:

Example 1

A 60-year-old male with no past 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 for flu shot twice a year. 

Example 2

A Fourteen-year-old male with no past medical history now presents for annual wellness visits and immunization in the hospital outpatient setting. The patient has no seasonal allergies in 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 a flu shot twice a year. 

Example 3

A Thirty-five-year-old male with no past 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 a flu shot twice a year. 

Example 4

An eighteen-year-old male with no past 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 a flu shot twice a year. 

Example 5

A Forty-four-year-old male with no past medical history now presents for a flu shot vaccine and routine check-up 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 are recommended for flu shots twice a year. 

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