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Ann Clin Transl Neurol (2019) 6(1):3345

Key Facts About CPT 90461 Service type: Immunization administration (add-on) Patient age: Through 18 years Requirement: Counseling by physician or qualified healthcare professional Reporting: Per additional component of each vaccine/toxoid Used with: CPT 90460 (first component) Common clinical indications: Routine pediatric immunizations Administration of combination vaccines (e.g., DTaP, MMR) Preventive care and well-child visits Catch-up immunization schedules When to Use CPT 90461 CPT 90461 is appropriate when: Administering vaccines to patients 18 years or younger A vaccine contains multiple components (antigens) Counseling is provided by the billing provider Reporting each additional component beyond the first Examples: Administering a combination vaccine with multiple antigens during a well-child visit Providing counseling and administering DTaP (which includes multiple components) Reporting additional components for MMR or other multi-antigen vaccines Catch-up immunization visits requiring multiple vaccines with multiple components Documentation Requirements To support CPT 90461 billing, documentation should include: Patient identifiers and date of service Patient age (must be 18 years) Vaccine(s) administered and number of components Confirmation of counseling provided Route of administration (if applicable) Vaccine lot number, manufacturer, and site of administration Immunization record updates Provider signature and credentials Clear documentation should support both the number of components and the counseling requirement

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