Summary & Overview
CPT 90460: Pediatric Immunization Administration with Counseling
CPT code 90460 represents the administration of immunizations to patients up to 18 years of age, with counseling provided by a physician or other qualified health care professional. This code is nationally significant as it supports preventive care efforts and ensures proper documentation and billing for pediatric immunizations, which are a cornerstone of public health. The code is applicable for the first or only component of each vaccine or toxoid administered during an office visit, typically in outpatient pediatric settings.
Major payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. Understanding how these payers process claims for CPT 90460 is crucial for providers and billing professionals seeking to optimize compliance and reimbursement.
Readers will gain insights into the clinical context of immunization administration, relevant policy updates, and coding benchmarks. The publication also addresses common modifiers, associated taxonomies, and related CPT codes, providing a comprehensive overview of the billing landscape for pediatric immunizations. This information is vital for healthcare organizations, clinicians, and billing teams aiming to stay current with national standards and payer requirements.
CPT Code Overview
CPT 90460 is used to report immunization administration for patients through 18 years of age, via any route of administration, when counseling is provided by a physician or other qualified health care professional. This code applies to the first or only component of each vaccine or toxoid administered during the encounter. The service type is Medicine – Immunization administration, and it is most commonly performed in an office setting, such as an outpatient pediatric clinic. This code is essential for documenting and billing immunization services that include counseling, ensuring accurate reimbursement and compliance with clinical guidelines.
Clinical & Coding Specifications
Clinical Context
A child under 18 years of age presents to a pediatrician's office for a routine well-child visit. During the encounter, the physician or other qualified health care professional provides counseling to the patient and/or their guardian regarding recommended immunizations. Following the counseling, the provider administers the first or only component of a vaccine or toxoid. The service is performed in an outpatient setting, such as an office (Place of Service 11). This scenario typically involves documentation of both the counseling and the administration of the immunization.
Coding Specifications
- Modifier
‑25: Used when a significant, separately identifiable evaluation and management (E/M) service is performed by the same physician on the same day as the immunization administration. Commonly reported with a well-child E/M visit.
| Provider Taxonomy Code | Specialty Name |
|---|---|
208000000X | Pediatrics |
207Q00000X | Family Medicine |
363L00000X | Nurse Practitioner |
363A00000X | Physician Assistant |
208D00000X | General Practice |
Related Diagnoses
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Z23: Encounter for immunization- Used when the primary purpose of the visit is to receive an immunization.
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Z00.129: Encounter for routine child health examination without abnormal findings- Used for well-child visits where no abnormalities are found, often paired with immunization administration.
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Z00.121: Encounter for routine child health examination with abnormal findings- Used for well-child visits where some abnormal findings are documented, and immunizations may still be administered.
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Z00.00: Encounter for general adult medical examination without abnormal findings- Used for adult routine exams without abnormalities; less commonly paired with pediatric immunization administration.
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Z00.01: Encounter for general adult medical examination with abnormal findings- Used for adult routine exams with abnormal findings; not typically paired with pediatric immunization administration.
Related CPT Codes
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90461: 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.- Used in conjunction with
90460when multiple components of a vaccine are administered during the same visit.
- Used in conjunction with
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90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid).- Used for immunization administration without counseling, or for patients over 18 years of age.
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90472: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid).- Used with
90471for each additional vaccine administered during the same visit.
- Used with
These codes are commonly used together when multiple vaccines or components are administered, or as alternatives depending on patient age and whether counseling is provided.
National Reimbursement Benchmarks
Medicare's national mean rate for CPT code 90460 is $24.20, which is lower than the BUCA (average commercial) mean rate of $26.99. Among the commercial payers, Aetna has the highest mean rate at $30.83, while UnitedHealth Group is at $25.99.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies across payers. Aetna shows the widest spread at $23.00, indicating significant variability in rates, while Medicare is the tightest with a range of only $2.00. Blue Cross Blue Shield and Cigna have moderate dispersion, at $11.50 and $9.00 respectively.
The table and chart below present the full breakdown of national benchmarks for CPT code 90460 across major payers.
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