Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Physician counseling not documented - should use 90471 instead
Very Common90460 requires face-to-face counseling by physician or qualified healthcare professional (QHP). If vaccine given by nurse without physician counseling, correct code is 90471. Denials occur when 90460 billed but no documentation of physician/QHP counseling session.
Common Causes
- • RN administered vaccine - no MD/DO/NP/PA counseling documented
- • VIS (Vaccine Information Statement) given to parent - not same as counseling
- • Brief mention of vaccine risks - not detailed counseling discussion
Resolution Strategy
Appeal requires documentation showing: physician or QHP (MD, DO, NP, PA) provided face-to-face counseling to parent/guardian, topics discussed (vaccine benefits, risks, side effects, VIS reviewed), parent questions answered, counseling documented in medical record (not just 'VIS provided'). If nurse-only administration without physician counseling, recode to 90471 (administration without counseling) and resubmit. 90460 reimbursement higher (~$30 vs ~$25) but requires physician/QHP involvement. Many practices default to 90471 to avoid documentation burden.
2. Component counting error - billing incorrect number of units
Very Common90460 is billed per vaccine component (antigen), not per injection. Common error: billing one unit for multi-component vaccine. Correct billing: DTaP (3 components) = 90460 x1 + 90461 x2, or billing each separate vaccine as 90460 when should be 90460 (first) + 90461 (additional).
Common Causes
- • DTaP billed as single 90460 - should be 90460 + 90461 + 90461 (3 components)
- • MMR billed as one unit - should be 90460 + 90461 + 90461 (measles, mumps, rubella)
- • Three separate vaccines given - billed as 90460 x3 - should be 90460 + 90461 + 90461
Resolution Strategy
Review vaccine administration record. Count total vaccine components (antigens): DTaP = 3, MMR = 3, IPV = 1, Hib = 1, Hepatitis B = 1. First component = 90460. Each additional component = 90461. Example: Well-child visit with DTaP + IPV = 4 total components = 90460 + 90461 + 90461 + 90461. Include vaccine administration documentation showing all vaccines given, each component counted separately. Most successful when corrected claim accurately reflects components administered.
3. Age restriction - 90460 only for patients through 18 years
Occasional90460/90461 are age-restricted codes: ONLY for patients birth through 18 years. For patients 19+ years, must use 90471/90472 regardless of whether counseling provided. Denials occur when 90460 used for adult patient.
Common Causes
- • 18-year-old patient - unclear if 18th birthday passed (use 90471 if 19+)
- • College student getting vaccines - provider assumes pediatric code appropriate
- • HPV vaccine at age 19-26 - should use 90471, not 90460
Resolution Strategy
Verify patient age at time of service. If 19+ years: recode to 90471/90472 (counseling not separately recognized for adults) and resubmit. If truly 18 years or younger: appeal with documentation showing patient birthdate confirming age ≤18 at vaccine administration. Age cutoff is strict - do not use 90460/90461 for any patient 19+ regardless of counseling provided. Adult vaccine administration always 90471/90472.
Relative Value Units (RVUs)
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Clinical Information
When to Use
First or only component of vaccine administration with counseling for patients through 18 years of age
Common Scenarios
Documentation Requirements
- Age documented (<18)
- Vaccine administered documented
- Counseling provided documented
- Patient/parent response to counseling
Coding Guidelines
Common Modifiers
Bundling Rules
- First or only component
- Includes counseling
- Age <18 only
- May be billed with vaccine product code
Exclusions
- Do not bill if age 18+ (use 90471)
- Do not bill with additional component codes on same vaccine
Coding Notes
Related CPT Codes
Clinical scenarios
- Age documented (<18)
- Vaccine administered documented
- Counseling provided documented
- Age documented (<18)
- Vaccine administered documented
- Counseling provided documented
- Age documented (<18)
- Vaccine administered documented
- Counseling provided documented
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Code Details
Medicare Pricing
PFSRVU Breakdown
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Ask a QuestionFrequently Asked Questions
CPT 90460 is the billing code for "Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered". First or only component of vaccine administration with counseling for patients through 18 years of age
Medicare pays approximately $22.32 for CPT 90460 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 90460 has a total RVU of 0.44, broken down as: Work RVU 0.17, Practice Expense RVU 0.25, and Malpractice RVU 0.02. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 90460 is "Physician counseling not documented - should use 90471 instead". 90460 requires face-to-face counseling by physician or qualified healthcare professional (QHP). If vaccine given by nurse without physician counseling, correct code is 90471. Denials occur when 90460 billed but no documentation of physician/QHP counseling session. Common causes include: RN administered vaccine - no MD/DO/NP/PA counseling documented; VIS (Vaccine Information Statement) given to parent - not same as counseling. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 90460 include: Age documented (<18); Vaccine administered documented; Counseling provided documented; Patient/parent response to counseling. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 90460: First or only component. Includes counseling Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 90460 include: 59 (Distinct procedural service when multiple procedures performed), 25 (Significant, separately identifiable evaluation and management service). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 90460 is Typically 5-10 minutes including counseling. Time-based codes require documentation of the actual time spent providing the service.