How To Use CPT Code 90696

CPT 90696 refers to the Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine and Inactivated Poliovirus Vaccine (DTaP-IPV), which is administered intramuscularly to children aged 4 through 6 years. This combination vaccine is crucial in preventing serious infectious diseases, including diphtheria, tetanus, pertussis, and poliovirus, thereby contributing to public health and individual immunity in the pediatric population.

1. What is CPT code 90696?

CPT code 90696 represents a combination vaccine that protects against four significant infectious diseases: diphtheria, tetanus, pertussis (whooping cough), and poliovirus. This vaccine is specifically designed for children aged 4 to 6 years and is administered intramuscularly, typically in the deltoid muscle of the upper arm. The purpose of this vaccine is to provide immunity against these diseases, which can lead to severe health complications. The DTaP-IPV vaccine is part of the routine immunization schedule for children, ensuring they receive the necessary protection as they grow and develop. The clinical relevance of this vaccine lies in its ability to prevent outbreaks of these diseases, which can be particularly dangerous in young children.

2. Qualifying Circumstances

The use of CPT code 90696 is appropriate under specific circumstances. It is intended for children who are between the ages of 4 and 6 years and who have previously received the initial doses of DTaP and/or DTaP HepB IPV vaccines. Children who have not received the required prior doses or who are younger than four years of age should not receive this vaccine. It is essential for healthcare providers to verify the vaccination history of the child before administering this combination vaccine to ensure compliance with immunization guidelines and to avoid any potential adverse reactions.

3. When To Use CPT 90696

CPT code 90696 is used when administering the DTaP-IPV vaccine to eligible children aged 4 to 6 years. It is important to document the administration of the vaccine accurately, including the route of administration and the specific vaccine given. This code should be reported alongside separate codes for the vaccine administration and any associated office visit, as per the documentation requirements. Additionally, providers should be aware of payer-specific guidelines, as some insurance companies may require the use of modifier 25 to indicate that a significant, separately identifiable evaluation and management service was performed on the same day as the vaccine administration. It is crucial to check with individual payers for their specific reporting guidelines to ensure compliance and proper reimbursement.

4. Official Description of CPT 90696

Official Descriptor: 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.

5. Clinical Application

CPT code 90696 is applied in clinical settings where immunization against diphtheria, tetanus, pertussis, and poliovirus is necessary for children aged 4 to 6 years. The administration of this vaccine is a critical component of pediatric healthcare, as it helps to establish immunity during a vulnerable period in a child’s development. The importance of this service cannot be overstated, as it not only protects the individual child but also contributes to herd immunity, reducing the overall incidence of these diseases in the community.

5.1 Provider Responsibilities

During the administration of the DTaP-IPV vaccine, the provider has several responsibilities. First, they must present the parent, guardian, or patient with information regarding the vaccine options available, discussing the risks, benefits, and potential side effects associated with the vaccine. Once the patient is adequately informed and consent is obtained, the provider prepares the vaccine for administration. The vaccine is then injected intramuscularly into the deltoid muscle of the upper arm, ensuring proper technique to minimize discomfort and maximize efficacy. Post-administration, the provider should monitor the patient for any immediate adverse reactions and provide guidance on follow-up care.

5.2 Unique Challenges

One of the unique challenges associated with administering the DTaP-IPV vaccine is ensuring that the child has received the appropriate prior vaccinations. Providers must carefully review the child’s immunization history to confirm eligibility for this combination vaccine. Additionally, addressing parental concerns about vaccine safety and efficacy can be challenging, requiring providers to be well-informed and prepared to discuss evidence-based information. There may also be logistical challenges in managing vaccine storage and handling, as well as ensuring that the administration process is efficient and comfortable for the child.

5.3 Pre-Procedure Preparations

Before administering the DTaP-IPV vaccine, providers must conduct a thorough evaluation of the child’s vaccination history to ensure they meet the criteria for receiving this vaccine. This includes confirming that the child is between the ages of 4 and 6 years and has received the necessary prior doses of DTaP and/or DTaP HepB IPV. Providers should also assess the child’s current health status, checking for any contraindications to vaccination, such as severe allergies or recent illnesses. Proper preparation also involves ensuring that the vaccine is stored correctly and is within its expiration date.

5.4 Post-Procedure Considerations

After administering the DTaP-IPV vaccine, the provider should monitor the child for any immediate adverse reactions, such as swelling, redness, or fever. Parents or guardians should be informed about potential side effects and advised on how to manage them at home. Follow-up care may include scheduling additional vaccinations as part of the child’s immunization schedule and providing educational materials about the importance of completing the vaccination series. Documentation of the vaccine administration must be completed accurately in the child’s medical record, including the date, vaccine lot number, and any other relevant information.

6. Relevant Terminology

Acellular pertussis: A highly infectious respiratory disease caused by the Bordetella pertussis bacteria, characterized by severe coughing fits.

Antibody: Proteins produced by the immune system in response to foreign substances, helping to neutralize pathogens like bacteria and viruses.

Antigen: Any substance that triggers an immune response, often a component of pathogens such as bacteria or viruses.

Antitoxin: An antibody that counteracts the effects of a toxin produced by bacteria.

Atrophy: A decrease in the size or wasting away of tissue or an organ.

Combination vaccine: A vaccine that includes components to protect against multiple diseases, reducing the number of injections needed.

Deltoid: The large, triangular muscle located on the upper arm, commonly used for intramuscular injections.

Diphtheria: A serious bacterial infection affecting the upper respiratory tract, caused by Corynebacterium diphtheriae.

DTaP IPV: A combination vaccine that provides protection against diphtheria, tetanus, pertussis, and poliovirus.

Immunization: The process of administering a vaccine to stimulate the immune system and provide protection against infectious diseases.

Inactivated: Refers to a virus or bacteria that has been killed or rendered non-infectious, used in vaccines.

Infectious: Capable of causing infection or disease.

Intramuscular: Referring to the administration of a substance directly into a muscle.

Polio: A viral disease that can cause paralysis and muscle atrophy, primarily affecting children.

Tetanus: A bacterial infection that causes muscle stiffness and spasms, commonly known as lockjaw.

Toxoids: Inactivated toxins used in vaccines to stimulate an immune response without causing disease.

Vaccine: A biological preparation that provides active acquired immunity to a particular infectious disease.

7. Clinical Examples

1. A 5-year-old child who has received the first three doses of DTaP and is due for their fifth dose of DTaP-IPV.

2. A parent brings their 4-year-old child for a routine check-up and vaccination, confirming that the child has received all previous vaccinations on schedule.

3. A healthcare provider discusses the benefits of the DTaP-IPV vaccine with a guardian, addressing concerns about vaccine safety.

4. A 6-year-old child presents for their school-required immunizations, including the DTaP-IPV vaccine.

5. A child who has recently recovered from a mild illness is evaluated to ensure they are healthy enough to receive the DTaP-IPV vaccine.

6. A provider administers the DTaP-IPV vaccine to a child while ensuring proper technique to minimize discomfort.

7. A parent is educated on the potential side effects of the DTaP-IPV vaccine and how to manage them at home.

8. A healthcare provider documents the administration of the DTaP-IPV vaccine in the child’s medical record, including the lot number and expiration date.

9. A child who has missed their scheduled vaccinations is brought in for catch-up immunizations, including the DTaP-IPV vaccine.

10. A healthcare provider reviews the immunization history of a 4-year-old child to confirm eligibility for the DTaP-IPV vaccine before administration.