As the case describes the procedure of vaccine administration, one should provide two types of codes. The first code would specify the type of vaccine administered to the patient. For the case under review, the appropriate CPT vaccine code is 90713, which stands for “poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use” (American Medical Association, 2020, p. 1495). This code is used only to identify the type of vaccine administered to the patient. It should be combined with another code that specifies the details of the vaccine administration procedure. Such specifications include the patient’s age and the route of administration. In the analyzed case, the patient is underage, and the vaccine is administered intramuscularly. Thus, the vaccine administration code reported in this situation would be 90460. It stands for “immunization administration through 18 years of age via any route of administration” (American Medical Association, 2020, p. 1485). It also covers the vaccination procedure performed by a physician or another qualified healthcare professional, which aligns with the case under review (American Medical Association, 2020). In brief, the two CPT codes applicable for the case are 90713 and 90460.
Vaccine coding is unique compared to other medical coding patterns and principles. It has a complex character as it includes at least two types of codes: for the vaccine type and the one with administration specifications. It is vital to record each performed vaccination accurately to eliminate further administration of incompatible toxoids or unnecessary repeated vaccination with the same component, which can cause overdose and become dangerous for the patient. Thus, the detailed and complex character of vaccine coding is justified by the risk of incompatibility of other immunization components or overdose.
Reference
American Medical Association. (2020). CPT/Current procedural terminology 2021: Professional edition. American Medical Association.