Reimbursement and coding information

Quick tips for coding Pentacel vaccine for reimbursement20

The American Medical Association established component-based vaccine administration codes effective 2011. Please review this page and its links for codes your practice may use on a regular basis to bill for Pentacel vaccine.

The following vaccine codes should be assigned on claims for Pentacel vaccine:

CPT®a Code

Code Description

90698

Source: 2008 Current Procedural Terminology

Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and poliovirus vaccine, inactivated (DTaP-Hib-IPV), for intramuscular use

Immunization administration codes

The current codes are based on the number of components in a vaccine. A component refers to all antigens in a vaccine that prevent disease caused by one organism. The codes are reported per component as follows:

Primary code (first vaccine or toxoid component)
90460	Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health-care professional.
Add-on code (each additional vaccine or toxoid component)
+90461	Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health-care professional. This code can only be reported in conjunction with the primary code, and replaces add-on codes 90466 and 90468.

As of January 1, 2011, the physician counseling codes (CPT 90465-90468) are no longer active
The long-standing codes for vaccine administration (CPT 90471-90474) will remain active and should be used when vaccines are administered with or without counseling to patients 19 years of age or older and if no counseling is provided to patients 18 years of age and younger

Healthcare Common Procedure Coding System Level II Modifiers (U Codes)

For more information on how to use the new component-based vaccine administration codes, please download this pdf.

New Component-Based Vaccine Administration Codes Effective 2011

Some Medicaid agencies and private health plans require the use of the 11-digit National Drug Code (NDC) in addition to the CPT code, on all claim forms for products administered by health-care providers. The NDC for Pentacel vaccine is:

NDC	Code Description
49281-0510-05	Pentacel vaccine 5-dose package

The following International Statistical Classification of Diseases and Related Health Problems (ICD) codes should be used for Pentacel vaccine when necessary:

ICD-9 Codes

Code Description

V06.3 and V03.81

(Typical ICD-9 code for Pentacel vaccine and its administration)

When Pentacel vaccine is used, it is necessary to report more than one ICD-9 code to reflect all diseases for which the vaccine is indicated. If your health plan or electronic billing system only allows for one ICD-9 code, we suggest the use of V06.8. (Other specified combination).

These codes are provided for your information only. It is the responsibility of the provider to determine the most appropriate code to use in billing for services rendered. The use of these codes does not guarantee payment.

aCPT = Current Procedural Terminology is a registered trademark of the American Medical Association.

Indication
Pentacel vaccine is indicated for active immunization against diphtheria, tetanus, pertussis, poliomyelitis, and invasive disease due to Haemophilus influenzae type b. Pentacel vaccine is approved for use as a 4-dose series in children 6 weeks through 4 years of age (prior to fifth birthday).

Safety Information
The most common local and systemic adverse reactions to Pentacel vaccine include injection site redness, swelling, and tenderness; fever, fussiness, and crying. Other adverse reactions may occur. Known systemic hypersensitivity reaction to any component of Pentacel vaccine or a life-threatening reaction after previous administration of the vaccine or a vaccine containing the same substances are contraindications to vaccination.

The decision to give Pentacel vaccine should be based on the potential benefits and risks; if Guillain-Barré syndrome has occurred within 6 weeks of receipt of a prior vaccine containing tetanus toxoid; or if adverse events have occurred in temporal relation to receipt of pertussis-containing vaccine. Encephalopathy within 7 days of administration of a previous dose of a pertussis-containing vaccine or a progressive neurologic disorder is a contraindication. Vaccination with Pentacel vaccine may not protect all individuals.

Before administering Pentacel vaccine, please see the full Prescribing Information.

Pentacel vaccine is manufactured by Sanofi Pasteur Limited and Sanofi Pasteur SA and distributed by Sanofi Pasteur Inc.