CPT Assistant provided a vignette for this code...
Clinical Example for Code 90465
The physician first reviews the patient's previous experience with the vaccine and determines if there are any contraindications prior to proceeding. A vaccine information sheet (VIS) is given to the parent or guardian for the DTaP vaccine, and, in keeping with state and federal laws, the information including risks and benefits of DTaP vaccine is discussed with the parent or guardian in detail. A discussion also occurs about the vaccine and the diseases it protects against. Appropriate documentation is entered into the patient record.
The documentation for the vaccine includes which VIS was given; the date of the publication of the VIS; the date the VIS was given; the name, address, and title of the person who administered the vaccine; the date of administration; the vaccine manufacturer; and the vaccine lot number. Additionally, the appropriate types and doses of medications to alleviate fever and pain at the injection site are discussed. Since the physician participates in the Vaccines for Children (VFC) program, the nurse obtains the vaccine from the appropriate inventory, documenting which supply of vaccines was used for this particular patient. Although federal law does not mandate separate vaccine inventories, the Centers for Disease Control and Prevention (CDC) strongly recommends them for reasons of accountability. Informed consent is obtained by the physician who then orders the nurse to prepare the vaccine. The nurse prepares and administers the DTaP vaccine using a safe, sharp syringe. After observing the patient in the office for an immediate allergic reaction, the patient is discharged home by the nurse. The immunization tracking number is entered into a computerized statewide registry.
And you are correct...90465 is for physician counseling. CPT Assist states it's appropriate to use code 90471 when the provider does not provide counseling.
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