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Vaccine details: manufacturer name, lot number, expiration date, and dosage amount Route of administration: intramuscular, subcutaneous, or intradermal Administration site: exact anatomical location (e.g., left deltoid, right anterolateral thigh) Date and provider: date of administration matching the claim, with signature or electronic authentication of the administering provider Patient consent: documented consent or refusal notation prior to administration ICD-10 diagnosis code: Z23 (Encounter for Immunization) linked in the record and on the claim Observation period: note any adverse reactions observed or confirm none occurred The lot number isn't optional and isn't a billing formality
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