How To Use CPT Code 90696

CPT 90696 refers to the administration of a combination vaccine for diphtheria, tetanus toxoids, acellular pertussis, and inactivated poliovirus for children aged 4 to 6 years. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT code 90696 procedures.

1. What is CPT 90696?

CPT 90696 is a medical billing code used to describe the administration of a combination vaccine for diphtheria, tetanus toxoids, acellular pertussis, and inactivated poliovirus (DTaP-IPV) to children between the ages of 4 and 6 years. This vaccine is administered intramuscularly and is essential for protecting children against these potentially life-threatening diseases.

2. 90696 CPT code description

The official description of CPT code 90696 is: “Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use.”

3. Procedure

The 90696 procedure involves the following steps:

1. The healthcare provider reviews the patient’s medical history and discusses the benefits, risks, and potential side effects of the DTaP-IPV vaccine with the parent, guardian, or patient.
2. The patient is appropriately prepped for the vaccine administration.
3. The healthcare provider administers the vaccine intramuscularly, typically in the deltoid muscle of the upper arm.
4. Post-vaccination, the healthcare provider monitors the patient for any immediate adverse reactions and provides necessary care if needed.
5. The healthcare provider documents the vaccine administration in the patient’s medical record, including the vaccine’s name, manufacturer, lot number, and expiration date.

4. Qualifying circumstances

Children between the ages of 4 and 6 years who have previously received DTaP and/or DTaP HepB IPV as the first three doses and DTaP as the fourth dose are eligible to receive CPT code 90696 services. The DTaP-IPV vaccine can be administered as the fifth dose of DTaP or as the fourth dose of IPV. Children younger than 4 years of age should not receive the DTaP-IPV vaccine.

5. When to use CPT code 90696

It is appropriate to bill the 90696 CPT code when a healthcare provider administers the DTaP-IPV vaccine to a child between the ages of 4 and 6 years, following the recommended immunization schedule. The vaccine should be administered as part of the child’s routine vaccination plan to ensure adequate protection against diphtheria, tetanus, pertussis, and poliovirus.

6. Documentation requirements

To support a claim for CPT 90696, the healthcare provider must document the following information in the patient’s medical record:

• Patient’s age and eligibility for the vaccine
• Date of vaccine administration
• Vaccine name, manufacturer, lot number, and expiration date
• Site and route of vaccine administration
• Any adverse reactions or side effects experienced by the patient
• Provider’s signature and credentials

7. Billing guidelines

When billing for CPT code 90696, medical professionals should adhere to the following guidelines:

• Report separate codes for vaccine administration, the actual vaccine, and an office visit, based on the documentation.
• Include sufficient documentation from the provider explaining the product administered, administration route, and purpose.
• Some insurance companies may require modifier 25 to be appended to the associated evaluation and management (E/M) code.
• Medicare and private insurance companies might have different guidelines for reporting vaccines or for reporting certain vaccines during the same visit, such as flu and pneumonia vaccines. Check with individual payers for their specific guidelines and have the policy in writing to protect your practice.

8. Historical information

CPT 90696 was added to the Current Procedural Terminology system on January 1, 2009. The code was changed on January 1, 2016, with the previous descriptor being “Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use.”

9. Similar codes to CPT 90696

Five similar codes to CPT 90696 and how they differentiate are:

1. CPT 90697: This code is for the administration of a diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, and Haemophilus influenzae type b conjugate vaccine (DTaP-IPV-Hib) for intramuscular use.
2. CPT 90698: This code is for the administration of a diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, and Haemophilus influenzae type b conjugate vaccine (DTaP-IPV-Hib-HepB) for intramuscular use.
3. CPT 90700: This code is for the administration of a diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP) for intramuscular use.
4. CPT 90702: This code is for the administration of a diphtheria and tetanus toxoids vaccine (DT) for intramuscular use.
5. CPT 90713: This code is for the administration of an inactivated poliovirus vaccine (IPV) for intramuscular or subcutaneous use.

10. Examples

Here are 10 detailed examples of CPT code 90696 procedures:

1. A 4-year-old child receives the DTaP-IPV vaccine during a routine well-child visit.
2. A 5-year-old child with a history of receiving the appropriate DTaP and IPV vaccines receives the DTaP-IPV vaccine as the fifth dose of DTaP and the fourth dose of IPV.
3. A 6-year-old child receives the DTaP-IPV vaccine prior to starting school, as required by the school’s immunization policy.
4. A 4-year-old child with a contraindication to the pertussis component of the vaccine receives the DTaP-IPV vaccine under the guidance of a healthcare provider.
5. A 5-year-old child receives the DTaP-IPV vaccine during a catch-up immunization visit after missing a previous vaccine appointment.
6. A 6-year-old child with a history of an incomplete immunization schedule receives the DTaP-IPV vaccine as part of a catch-up vaccination plan.
7. A 4-year-old child with a history of a severe allergic reaction to a previous DTaP vaccine receives the DTaP-IPV vaccine under close medical supervision.
8. A 5-year-old child receives the DTaP-IPV vaccine during a visit to a travel clinic in preparation for international travel.
9. A 6-year-old child receives the DTaP-IPV vaccine at a community health clinic during a vaccination campaign.
10. A 4-year-old child with a chronic medical condition receives the DTaP-IPV vaccine as part of a comprehensive immunization plan developed by a healthcare provider.