Three Current Procedural Terminology codes for immunization counseling on days when no vaccine is administered, 90482 through 90484, took effect Jan. 1, 2026. They were built to capture the time a physician spends on a conversation that ends without a shot. CMS does not pay for them, and most private payers do not either.

Medical Economics Associate Editor Austin Littrell sat down with Sarah C. Nosal, M.D., FAAFP, president of the American Academy of Family Physicians and a family physician who has practiced in the South Bronx for nearly two decades.

Nosal points family physicians to the AAFP's 2026 immunization schedules, developed with input from other medical organizations and the Vaccine Integrity Project. In this episode, she explains why most childhood doses are still given in a primary care office, what a practice gives up when it stops stocking and starts sending patients to a pharmacy, and how she handles a visit that opens with exemption paperwork instead of a question. Read the full written Q&A with Nosal.

This conversation was recorded before the Aug. 10 executive order calling for universal childhood vaccine recommendations to cover 11 diseases rather than 18. Nosal does not address the order here.

Music Credits:
Coffee Shop Sketches by Buurd - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.

0:00 – 0:20 | Cold open. Nosal on the one thing every parent walking into the exam room has in common, whether they came for a shot or an exemption.

0:20 – 1:49 | Introduction. Austin Littrell introduces the episode and the guest.

1:49 – 2:23 | Which schedule to work from. Nosal points family physicians to the AAFP's recommendations, developed with other major medical organizations and the Vaccine Integrity Project.

2:23 – 3:25 | What shared decision-making actually means. More vaccines sit in that category than a year ago. Nosal argues it describes what family physicians already do at every visit: answer the questions, offer the information the patient did not know to ask for, and let them decide.

3:25 – 5:15 | Does stocking vaccines still pencil out. Vaccines are expensive and reimbursement is the common complaint, but most childhood doses are still given in a family physician's office. Large networks with capital and in-house pharmacies have squeezed the smaller practices.

5:15 – 6:11 | The counseling codes nobody pays for. Practices can document the work and use the codes. CMS does not reimburse them, most private payers do not either, and the AAFP is still advocating.

6:11 – 7:30 | When a family brings exemption paperwork. Nosal's approach: acknowledge the form, ask what they are thinking, and partner instead of argue.

7:30 – 9:13 | Where the AAFP lands on staggered schedules. The full regimen at each scheduled appointment. Nosal will not turn a family away for declining, but says most parents choose the traditional schedule once they have had the conversation.

9:13 – 10:04 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

10:04 – 11:52 | What actually moves a parent. Setting the expectation months ahead rather than at the visit, then walking a family through the specific worry until they talk themselves out of it.

11:52 – 13:18 | Longitudinal relationships under pressure. Consolidation, panel size and short visits are eroding the model. Nosal describes working around it in an under-resourced community by treating the whole family as the unit of care.

13:18 – 14:49 | What a practice loses at the pharmacy counter. Pharmacies often will not vaccinate infants or children, registry reporting is inconsistent from state to state, and patients end up with records nobody can reconcile.

14:49 – 15:56 | Why she does not say "hesitancy". Nosal closes on parents who are not hesitant so much as working from information that does not line up.

15:56 – 17:04 | Closing thoughts and outro. Littrell thanks Nosal and wraps the episode.

S1 Ep179: Vaccine schedules, stocking costs and the back-to-school visit, with AAFP President Sarah Nosal, M.D.

Off the Chart: A Business of Medicine Podcast

S1 Ep179: Vaccine schedules, stocking costs and the back-to-school visit, with AAFP President Sarah Nosal, M.D.