CPT code 90697 is a specific code used to identify the DTaP-IPV-Hib-HepB vaccine for healthcare providers in documentation and reporting.
CPT code 90697 is used to identify the administration of a combination vaccine that includes DTaP (Diphtheria, Tetanus, and acellular Pertussis), IPV (Inactivated Poliovirus), Hib (Haemophilus influenzae type b), and HepB (Hepatitis B). This vaccine is administered intramuscularly (IM) and is designed to protect against multiple infectious diseases with a single injection. The use of this code in medical billing ensures that healthcare providers are accurately reimbursed for the administration of this comprehensive immunization, which is particularly beneficial in pediatric care to reduce the number of injections a child receives.
For CPT code 90697, which pertains to the administration of the DTaP-IPV-Hib-HepB vaccine intramuscularly, 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. Although not commonly used with vaccine administration, this modifier may be applicable if the vaccine administration is part of a telemedicine service where the provider is guiding the administration remotely.
6. Modifier SL: State Supplied Vaccine. This modifier is used when the vaccine is supplied by the state, indicating that the provider did not incur the cost of the vaccine.
These modifiers help ensure accurate billing and reimbursement by providing additional context about the services rendered. It is important to use them appropriately to avoid claim denials or delays.
The CPT code 90697, which is associated with a specific vaccine, is subject to reimbursement considerations under Medicare. To determine if Medicare reimburses this code, one must refer to the Medicare Physician Fee Schedule (MPFS), which outlines the payment rates for services and procedures covered by Medicare. Additionally, the reimbursement status can vary based on the policies of the Medicare Administrative Contractor (MAC) that processes claims in a specific geographic region. Each MAC may have different guidelines and coverage determinations, so it is essential to verify with the relevant MAC to confirm if CPT code 90697 is reimbursed under Medicare in your area.
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