How To Use CPT Code 90461

CPT 90461 refers to the administration of an additional vaccine or toxoid component to a patient up to 18 years of age, with counseling by a physician or other qualified health care professional. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT code 90461.

1. What is CPT 90461?

CPT 90461 is a medical billing code used to report the administration of an additional vaccine or toxoid component to a patient up to 18 years of age, with counseling by a physician or other qualified health care professional. This code is used in conjunction with the primary vaccine administration code, CPT 90460, and is essential for accurate billing and reimbursement for the additional vaccine or toxoid component administered during the same encounter.

2. 90461 CPT code description

The official description of CPT code 90461 is: “Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)”.

3. Procedure

1. The provider evaluates the patient’s immunization history and determines the need for an additional vaccine or toxoid component.
2. The provider counsels the patient or their guardian about the additional vaccine or toxoid component, including its benefits, risks, and potential side effects.
3. The provider prepares the additional vaccine or toxoid component for administration.
4. The additional vaccine or toxoid component is administered to the patient via the appropriate route (e.g., intramuscular, subcutaneous, oral, intranasal).
5. The provider documents the administration of the additional vaccine or toxoid component in the patient’s medical record, including the date, time, and route of administration.

4. Qualifying circumstances

Patients eligible to receive CPT code 90461 services are those up to 18 years of age who require an additional vaccine or toxoid component during the same encounter as the primary vaccine administration. This may include patients who are due for multiple vaccinations according to their immunization schedule or those who require additional protection due to specific health conditions or risk factors.

5. When to use CPT code 90461

It is appropriate to bill the 90461 CPT code when an additional vaccine or toxoid component is administered to a patient up to 18 years of age during the same encounter as the primary vaccine administration, and counseling is provided by a physician or other qualified health care professional. This code should be used in conjunction with the primary vaccine administration code, CPT 90460, to ensure accurate billing and reimbursement.

6. Documentation requirements

To support a claim for CPT 90461, the following information should be documented in the patient’s medical record:

• Patient’s age at the time of the encounter
• Immunization history and the need for the additional vaccine or toxoid component
• Counseling provided by the physician or other qualified health care professional, including the benefits, risks, and potential side effects of the additional vaccine or toxoid component
• Preparation and administration of the additional vaccine or toxoid component, including the date, time, and route of administration
• Any adverse reactions or side effects experienced by the patient following the administration of the additional vaccine or toxoid component

7. Billing guidelines

When billing for CPT code 90461, it is essential to follow the appropriate guidelines and rules to ensure accurate reimbursement. This includes reporting the code in conjunction with the primary vaccine administration code, CPT 90460, and listing it separately on the claim form. Additionally, it is crucial to document all necessary information in the patient’s medical record to support the claim, as outlined in the documentation requirements section.

8. Historical information

CPT 90461 was added to the Current Procedural Terminology system on January 1, 2011. The code’s description was changed on January 1, 2012, to include the phrase “with counseling by physician or other qualified health care professional” to clarify the requirement for counseling during the administration of the additional vaccine or toxoid component.

9. Similar codes to CPT 90461

Five similar codes to CPT 90461 include:

1. CPT 90460: This code is used for the primary vaccine administration to a patient up to 18 years of age, with counseling by a physician or other qualified health care professional.
2. CPT 90471: This code is used for immunization administration without counseling for patients of any age.
3. CPT 90472: This code is used for each additional vaccine or toxoid component administered without counseling for patients of any age.
4. CPT 90473: This code is used for immunization administration by intranasal or oral route for patients of any age.
5. CPT 90474: This code is used for each additional vaccine or toxoid component administered by intranasal or oral route for patients of any age.

10. Examples

Here are 10 detailed examples of CPT code 90461 procedures:

1. A 4-month-old infant receives the primary DTaP vaccine (CPT 90460) and an additional Hib vaccine (CPT 90461) during the same encounter, with counseling provided by the physician.
2. A 12-year-old patient receives the primary HPV vaccine (CPT 90460) and an additional meningococcal vaccine (CPT 90461) during the same encounter, with counseling provided by a nurse practitioner.
3. An 18-month-old child receives the primary MMR vaccine (CPT 90460) and an additional varicella vaccine (CPT 90461) during the same encounter, with counseling provided by the physician.
4. A 6-year-old patient receives the primary inactivated influenza vaccine (CPT 90460) and an additional pneumococcal vaccine (CPT 90461) during the same encounter, with counseling provided by a physician assistant.
5. A 15-year-old patient receives the primary Tdap vaccine (CPT 90460) and an additional hepatitis A vaccine (CPT 90461) during the same encounter, with counseling provided by the physician.
6. An 11-year-old patient receives the primary meningococcal vaccine (CPT 90460) and an additional HPV vaccine (CPT 90461) during the same encounter, with counseling provided by a nurse practitioner.
7. A 2-month-old infant receives the primary rotavirus vaccine (CPT 90460) and an additional DTaP vaccine (CPT 90461) during the same encounter, with counseling provided by the physician.
8. A 4-year-old patient receives the primary inactivated influenza vaccine (CPT 90460) and an additional MMR vaccine (CPT 90461) during the same encounter, with counseling provided by a physician assistant.
9. A 16-year-old patient receives the primary meningococcal B vaccine (CPT 90460) and an additional hepatitis B vaccine (CPT 90461) during the same encounter, with counseling provided by the physician.
10. An 8-year-old patient receives the primary varicella vaccine (CPT 90460) and an additional inactivated influenza vaccine (CPT 90461) during the same encounter, with counseling provided by a nurse practitioner.