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A compliant 90471 encounter should include Dose administered Patient or guardian consent Provider signature or e-signature Injection site (left deltoid, right thigh, etc.) Route (IM, SQ, intradermal, or percutaneous) Observation period and any adverse reactions noted Vaccine name, manufacturer, lot number, and expiration date Vaccine Information Statement (VIS) provided to the patient (federal law requires VIS distribution for all CDC-covered vaccines) The ICD-10 code Z23 ( Encounter for immunization ) is the standard diagnosis pairing for routine preventive vaccines

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Cycle breaks become mandatory if you have been on protocol for 12+ weeks continuously or if response has dropped significantly despite dose adjustment

PubMed Wang, Y., Feng, Z., & Yu, L