Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use, 3 years of age and older
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Vaccine product code billed without administration code
Very Common90686 (influenza vaccine product) must be billed with administration code (90471 for adults, 90460/90461 for children with counseling). Product code alone will deny - insurance expects both vaccine supply AND administration service billed together.
Common Causes
- • Only vaccine product code submitted - no administration code
- • Administration code denied - product code also denied as dependent
- • Billing system separated product and administration codes onto different claims
Resolution Strategy
Submit corrected claim with both codes: 90686 (vaccine product) + 90471 (administration for adults) OR 90686 + 90460 (administration with counseling for children). Both components required for complete vaccine service. Total reimbursement typically ~$50 ($25 product + $25 administration). Include lot number, manufacturer, expiration date, administration date, and site of injection documentation.
2. Flu vaccine given outside flu season - seasonal restriction
OccasionalInfluenza vaccine coverage typically limited to flu season (roughly August/September through March). Some payers deny flu vaccine claims outside this window, or require special justification for off-season vaccination.
Common Causes
- • Flu vaccine administered April-July (outside typical flu season)
- • Patient traveling to Southern Hemisphere during off-season - not documented
- • High-risk patient (immunocompromised) requiring year-round protection - not justified
Resolution Strategy
For flu vaccine outside typical season, appeal with justification: patient traveling to area with active flu season (Southern Hemisphere during Northern summer), high-risk patient requiring year-round protection (severely immunocompromised, transplant recipient), vaccine unavailable during traditional season and patient now requesting catch-up vaccination. If no special circumstance, flu vaccine given April-July may be denied as outside season. Most payers cover flu vaccine September-March without issue.
3. Duplicate flu vaccine same season - only one annual flu shot covered
CommonInsurance covers one flu vaccine per flu season (typically July-June coverage year). Denials occur when second flu vaccine billed same season, or when patient received flu shot at different location (pharmacy, employer clinic) and office-administered vaccine is duplicate.
Common Causes
- • Patient got flu shot at pharmacy in September, presents to office for shot in November
- • Two doses billed for adult (only children <9 require two-dose initial series)
- • Patient changed insurance mid-year - new plan shows duplicate vaccine
Resolution Strategy
Verify patient vaccine history. If patient truly did not receive flu vaccine earlier same season, appeal with documentation showing: patient vaccine record with no prior flu vaccine documented for current season, patient statement denying prior vaccination, or records from other providers showing no flu vaccine given. If patient did receive prior flu vaccine same season, duplicate denial is appropriate - only one flu shot per season covered. Exception: children <9 years getting first-time flu vaccine require two doses 4+ weeks apart - both covered with documentation.
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Clinical Information
When to Use
Quadrivalent influenza vaccine, split virus, preservative-free, age 3+
Common Scenarios
Documentation Requirements
- Age documented (3+)
- Vaccine product documented
- Patient response
Coding Guidelines
Common Modifiers
Bundling Rules
- Vaccine product code
- Age 3+ only
- Bill separately from administration
Exclusions
- Do not bill if age <3
- Do not bill with administration included
Coding Notes
Clinical scenarios
- Age documented (3+)
- Vaccine product documented
- Patient response
- Age documented (3+)
- Vaccine product documented
- Patient response
- Age documented (3+)
- Vaccine product documented
- Patient response
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Code Details
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Ask a QuestionFrequently Asked Questions
CPT 90686 is the billing code for "Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use, 3 years of age and older". Quadrivalent influenza vaccine, split virus, preservative-free, age 3+
The most common denial reason for CPT 90686 is "Vaccine product code billed without administration code". 90686 (influenza vaccine product) must be billed with administration code (90471 for adults, 90460/90461 for children with counseling). Product code alone will deny - insurance expects both vaccine supply AND administration service billed together. Common causes include: Only vaccine product code submitted - no administration code; Administration code denied - product code also denied as dependent. Appeal success rate is approximately 70-80%.
Key documentation requirements for CPT 90686 include: Age documented (3+); Vaccine product documented; Patient response. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 90686: Vaccine product code. Age 3+ only Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 90686 include: 59 (Distinct procedural service). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 90686 is Vaccine product code. Time-based codes require documentation of the actual time spent providing the service.