CPT® Code 90471 – Immunization Administration (First Vaccine or Toxoid)

November 18, 2025

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3 min read

Office or Outpatient Setting for Initial Vaccine Administration
CPT® code 90471 is used to report the administration of a single vaccine or toxoid during an encounter. This code covers the professional service associated with preparing, counseling, and administering the first vaccine dose or toxoid injection. It includes all necessary steps such as patient education, consent, and documentation, and applies to intramuscular, subcutaneous, or intradermal injections.

When to Use CPT® Code 90471
Report 90471 when:

The provider administers the first vaccine or toxoid during a visit.
The service includes counseling the patient or guardian, preparing the vaccine, and performing the injection.
The administration is distinct from the vaccine product itself (which is billed separately).
The injection method is intramuscular, subcutaneous, or intradermal.

For each additional vaccine administered during the same encounter, use add-on code 90472.

Documentation Requirements
Accurate and complete documentation ensures proper reimbursement and compliance. Include:

Date and time of vaccine administration
Vaccine name, manufacturer, lot number, and expiration date
Injection site and route (IM, SC, or ID)
Patient or guardian consent
Counseling details, if provided
Provider credentials and signature

Documentation should clearly distinguish the administration service (90471) from the vaccine product code (e.g., 90686 for influenza vaccine).

Billing Guidelines

90471 covers the administration of the first vaccine or toxoid during a patient encounter.
Use 90472 for each additional vaccine administered at the same visit.
Bill the vaccine product separately using the appropriate CPT® or HCPCS code.
The same code applies to all administration routes unless the vaccine is given intranasally or orally (use 90473/90474 for those).
Payers may require vaccine counseling documentation, especially for pediatric patients under the Vaccines for Children (VFC) program.
Always verify payer-specific billing rules for vaccine administration combinations.

Example
A provider administers an influenza vaccine intramuscularly to a patient during a preventive visit. The service includes patient education and consent. The vaccine itself is billed using CPT® 90686, and the administration is billed using CPT® 90471 for the first injection.

Streamline Immunization Documentation with OptiMantra
Managing vaccine administration is simple and efficient with OptiMantra. The platform automatically records vaccine details, lot numbers, injection sites, and patient consent within customizable chart templates. Providers can link each vaccine to its administration code for accurate billing and compliance. With OptiMantra, you can ensure seamless documentation, reduce manual entry, and simplify reporting for both pediatric and adult immunizations.

Try OptiMantra for free here!

Jessica Castro

Jessica is a Massachusetts-based LPN with 13+ years of experience in patient care, healthcare technology, and education. As the Implementation and Customer Success Manager at OptiMantra, she helps providers optimize EMR solutions for better workflows and patient outcomes. With a Bachelor's in Community Health and a Master's in Healthcare Innovation in progress, she is passionate about leveraging technology to improve care delivery. Through her writing, she shares insights on healthcare best practices, EHR optimization, and patient advocacy to support providers in delivering exceptional care.

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