Pediatric Coding Alert

Question: We have a physician in our practice who orders nurses to administer 90696 to kids outside of the 4 to 6-year-old age range because they are behind on their DTaP-IPV vaccination schedule. Is it OK to bill that code, or should we bill 90700 with 90713?

Texas Subscriber

Answer: The answer to your question can be found in the introduction to the Vaccine, Toxoids section of CPT^®, which states “The ‘when administered to’ age descriptions included in CPT^® vaccine codes are not intended to identify a product’s licensed age indication.” In other words, when a code includes an age range in its descriptor, you are not limited to administering the vaccine or the dose to patients in that range.

However, you must assign the code that most accurately describes the vaccine that your nurse administered. So, if the nurse administered the combination vaccine 90696 (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), you must not document 90700 (Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use) and 90713 (Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use), as this does not document the service that was provided to your patient.

However, the Food and Drug Administration (FDA) has only approved Kinrix and Quadracel, the two widely used combination vaccines, for children in the 4 to 6-year age range. This means that if your nurse uses either one to vaccinate a 7 year old, your insurance carrier may view the use as experimental (because they have not been declared effective outside of the age range stipulated in the drugs’ packaging). Consequently, the payer may not pay for use of the vaccine, leaving your patient to foot the bill.