Overview
CPT® Code 90460 is used to report the administration of intramuscular vaccines or toxoids to children and adolescents 18 years or younger, specifically for the first or only component of the immunization. This code captures the professional service of giving the vaccine, separate from the cost of the vaccine itself, which is billed with the appropriate CPT or HCPCS vaccine code.
90460 is commonly used during routine pediatric or adolescent immunization visits to ensure compliance with preventive care recommendations and CDC immunization schedules.
Key Facts About CPT® 90460
- Service type: Vaccine administration
- Provider type: Physicians, nurse practitioners, physician assistants, and qualified healthcare professionals
- Medical services included:
- Intramuscular injection of vaccine or toxoid
- Counseling to parent/guardian or patient regarding vaccine benefits, risks, and side effects
- Documentation of administration in the patient record
- Patient population: Children and adolescents aged 18 years or younger
- Common clinical indications:
- Routine childhood immunizations (e.g., DTaP, IPV, Hepatitis B)
- Adolescent immunizations (e.g., HPV, Tdap)
- Catch-up immunizations for missed doses
- Preventive care and public health compliance
When to Use CPT® 90460
CPT 90460 is appropriate when:
- Administering the first or only component of a vaccine via intramuscular injection
- The patient is 18 years old or younger
- The provider documents vaccine administration, counseling, and informed consent
- This service is billed separately from the vaccine product
Examples:
- Administering the first dose of the DTaP series to a 2-year-old
- Providing the only Tdap booster to a 16-year-old
- Intramuscular hepatitis B vaccine during routine well-child visits
- Counseling and vaccine administration during an adolescent preventive care visit
Documentation Requirements
To properly support CPT 90460 billing, documentation should include:
- Patient identifiers and date of service
- Vaccine or toxoid administered
- Route of administration (intramuscular)
- Number of components administered (first or only)
- Counseling provided to patient/parent regarding risks, benefits, and side effects
- Any observed reactions or follow-up instructions
Comprehensive documentation ensures compliance, proper reimbursement, and accurate immunization tracking.
Reimbursement and Coding Considerations
- CPT 90460 is reimbursed separately from the vaccine product (e.g., DTaP, HPV, MMR)
- Use 90461 for each additional component administered in the same visit
- CPT 90460 is generally covered by Medicare, Medicaid, and commercial payers when age and administration criteria are met
- Ensure accurate coding of patient age and route of administration
- Documentation must support counseling and informed consent for preventive care compliance
How OptiMantra Supports Pediatric Vaccine Administration
OptiMantra’s integrated EMR and practice management platform streamlines documentation, tracking, and billing for immunization services like CPT 90460.
With OptiMantra, providers can:
- Record vaccine administration with structured templates for route, dose, and component
- Track patient age, vaccine schedules, and preventive care compliance
- Document counseling and follow-up instructions for patients and guardians
- Generate audit-ready, compliant claims for vaccine administration codes
- Integrate immunization records into the patient’s longitudinal care plan
By centralizing vaccination documentation, billing, and tracking, OptiMantra ensures accuracy, compliance, and efficient preventive care delivery.
Try OptiMantra for free here!
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