Use These New Immunization Counseling Codes in Your Practice, Part 2
Documentation will be key to new code reimbursement. Last month, Revenue Cycle Insider discussed in detail three new CPT® codes that can be used when patients or families are hesitant about the practitioner administering suggested vaccines. In the second part of this series, you’ll learn more details regarding the relative value units (RVU)s, how different payers are treating these codes, and how documentation will be helpful toward reimbursement when using them. Refresh Your Code Knowledge When three new CPT® codes took effect on January 1, they, for the first time, allowed pediatric clinicians to report immunization counseling when recommended vaccines are refused or deferred. In theory, these codes recognize the significant clinical time and cognitive labor involved in addressing vaccine hesitancy. In practice, early payer guidance suggests a familiar reality: uneven adoption, inconsistent coverage, and ongoing operational uncertainty. The new codes are: This update reflects what is currently known about payer policies, documentation expectations, and early reimbursement considerations. See What the Codes Are Designed to Do CPT® codes 90482-90484 are time-based, standalone counseling codes intended for use only when a recommended vaccine is not administered. They require face-to-face counseling with a parent or guardian and must be distinct from any evaluation and management (E/M) service or vaccine administration provided during the same visit. While other vaccines may be given on the same date, counseling time related to administered vaccines must be excluded. You can only report one code per patient, per visit. When paired with ICD-10-CM codes such as Z71.85 (Encounter for immunization safety counseling) and Z28.xx (Immunization not carried out and underimmunization status), these services also allow more accurate tracking of vaccine hesitancy as a clinical and public health issue. Documentation Will Be Necessary, but Not Punitive As with any new codes, documentation will be essential. Records should identify the vaccines that were not administered, describe the information covered in the counseling (including benefits, risks, safety, and consequences of non-vaccination), clearly state total counseling time attributable only to refused or deferred vaccines, and document parental refusal or deferral. Counseling must be explicitly noted as separate and distinct from other services. The intent of these codes is to support thoughtful, sustained engagement with hesitant families — not to create documentation traps or audit vulnerability. Reasonable, clinically grounded documentation should be sufficient. Early Payer Guidance Is a Mixed Landscape Early payer guidance reflects a mixed landscape — an outcome that is not entirely surprising. Codes 90482-90484 are not tied to a U.S. Preventive Services Task Force (USPSTF) A or B preventive service recommendation and therefore are not subject to preventive coverage mandated by the Affordable Care Act (ACA). In the absence of that policy lever, payer adoption is discretionary, leading to variability in coverage determinations, benefit classification, and payment decisions. National commercial payer policies are beginning to emerge. UnitedHealthcare and Cigna have both published policies recognizing these codes and allowing coverage under preventive benefits. While implementation details will still matter, these policies suggest a willingness to operate the codes as intended, without patient cost-sharing. In contrast, Blue Cross Blue Shield of Massachusetts has placed 90482-90484 on its nonpayment list. Providers are being advised to continue reporting the following codes for vaccine counseling instead: This approach is problematic: unlike 90482, which begins at three minutes, 99401 requires a minimum of eight minutes and was not designed specifically for immunization refusal counseling. The result is a mismatch between clinical reality and reporting options, undermining the very purpose of the new codes. At present, payer guidance remains unclear for most other plans and regional carriers, reinforcing the need for payer-specific verification before implementation. Know RVUs and Early Fee-Setting Considerations For Massachusetts, the 2026 nonfacility work RVUs for these services are: Using 90482 as an example and applying the 2026 Medicare work RVU conversion factor of $33.40, the estimated baseline charge would be calculated as follows: 33.40 × 0.44 ≈ $14.70. This amount can reasonably serve as an initial baseline. Depending on the practice’s pricing methodology and market considerations, additional approaches may be applied to establish the final charge. As with many newly introduced CPT® codes, fee schedules are expected to evolve as real-world reimbursement patterns emerge. Until such data is available, transparent and defensible pricing — combined with a willingness to reassess and adjust — remains essential. Codes Promise Progress, but Not Without Friction These new codes represent meaningful progress in aligning reimbursement with the realities of pediatric care. They validate the time spent addressing vaccine hesitancy, improve data capture regarding underimmunization, and support deeper clinical engagement rather than rushed conversations. Whether that promise is realized will depend on payer adoption, operational readiness, and thoughtful implementation. Practices should proactively engage contracted payers, clarify coverage and documentation expectations, and prepare front-end staff to communicate clearly with families about potential financial responsibility. Donna Walaszek, CCS-P, Billing Manager, Northampton Area Pediatrics, Northampton Massachusetts
