2025 CPT code 90471
(Active) Effective Date: N/A Revision Date: N/A Medicine - Immunization Administration for Vaccines/Toxoids Medicine Services and Procedures Feed
Administration of the first vaccine (single or combination vaccine/toxoid) via percutaneous, intradermal, subcutaneous, or intramuscular injection.
Modifiers may apply depending on the circumstances of service. Consult the CPT manual for detailed guidance on modifier usage.Modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day) might apply in cases where a significant separate E/M service is provided on the same day.
Medical necessity is established by the patient's age and the recommended immunization schedule.The vaccine must be appropriate for the patient's age and health status.
The clinical responsibility involves prepping the patient and administering the vaccine or vaccines via the appropriate route (percutaneous, intradermal, subcutaneous, or intramuscular). The provider is responsible for ensuring the correct vaccine is given and for properly documenting the administration.
In simple words: This code covers giving a patient their first shot of a vaccine.The shot can be given under the skin, into a muscle, or through other methods.This doesn't include any extra advice given with the shot.
CPT code 90471 represents the administration of a single or combination vaccine or toxoid, administered via percutaneous, intradermal, subcutaneous, or intramuscular injection.This code is reported for the initial vaccine administered during an encounter.It does not include counseling.Additional vaccines administered during the same encounter would require the use of code 90472. For patients 18 years and older, or when no face-to-face counseling is provided, this code is used for the initial vaccination; additional vaccines require code 90472. This code excludes influenza vaccines.
Example 1: A 6-month-old infant receives their first dose of the DTaP vaccine via intramuscular injection. Code 90471 is reported., A 15-year-old adolescent receives their first dose of the HPV vaccine via intramuscular injection.The physician provides counseling before administering the shot.Code 90460 is reported, not 90471., A 25-year-old adult receives their first dose of the COVID-19 vaccine via intramuscular injection. Code 90480 is reported; 90471 is not used for COVID-19 vaccines.
Documentation should include the date of administration, the vaccine(s) administered (including manufacturer and lot number), the route of administration, the site of injection, and the patient's age.If applicable, documentation of counseling should also be included.
** This code should only be reported once per encounter for the first vaccine or toxoid administered.Always check for payer-specific guidelines before billing.