CPT code 90685 is a code used to identify the administration of a specific influenza vaccine without preservatives, given via injection.
CPT code 90685 is used to describe an influenza virus vaccine, quadrivalent (IIV4), split virus, preservative-free, for intramuscular use, specifically in a 0.25 mL dosage. This code is typically used for billing purposes when administering this particular flu vaccine to patients, often children, as the 0.25 mL dosage is suitable for younger age groups. The "quadrivalent" aspect indicates that the vaccine is designed to protect against four different flu virus strains, enhancing its effectiveness. The "preservative-free" designation is important for patients who may have sensitivities or allergies to preservatives commonly found in vaccines.
For CPT code 90685, which pertains to the administration of a specific vaccine, the following modifiers may be applicable:
1. Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. This modifier is used when a significant, separately identifiable evaluation and management service is performed by the same physician on the same day as the vaccine administration.
2. Modifier 59: Distinct Procedural Service. This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. It may be applicable if multiple vaccines are administered and need to be distinguished from one another.
3. Modifier 76: Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional. This modifier is used if the same vaccine is administered more than once on the same day by the same provider.
4. Modifier 77: Repeat Procedure by Another Physician or Other Qualified Health Care Professional. This modifier is used if the same vaccine is administered more than once on the same day by a different provider.
5. Modifier 95: Synchronous Telemedicine Service Rendered via a Real-Time Interactive Audio and Video Telecommunications System. This modifier is used if the vaccine administration is part of a telemedicine service, although this is less common for vaccine administration.
6. Modifier SL: State Supplied Vaccine. This modifier is used when the vaccine is supplied by the state and not billed to the patient or insurance.
These modifiers help clarify the circumstances under which the vaccine is administered and ensure accurate billing and reimbursement. Always verify with the latest coding guidelines and payer-specific requirements, as these can vary.
CPT code 90685 is associated with a specific service that may be reimbursed by Medicare, but its reimbursement is contingent upon several factors. The Medicare Physician Fee Schedule (MPFS) is a critical resource that determines whether a particular CPT code is covered and the reimbursement rate for services provided to Medicare beneficiaries. To ascertain if CPT code 90685 is reimbursed, healthcare providers should consult the MPFS to verify its inclusion and the associated payment details.
Additionally, Medicare Administrative Contractors (MACs) play a significant role in the reimbursement process. MACs are responsible for processing Medicare claims and have the authority to make coverage determinations within their jurisdictions. Therefore, it is essential for healthcare providers to check with their specific MAC to confirm whether CPT code 90685 is reimbursed in their region and to understand any local coverage determinations or guidelines that may apply.
In summary, while CPT code 90685 may be reimbursed by Medicare, providers must verify its status on the MPFS and consult their MAC for specific coverage and reimbursement details.
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