Appendix A Well Child Check-Up (EPSDT)
Appendix A Well Child Check-Up (EPSDT)
Appendix A Well Child Check-Up (EPSDT)
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>Well</strong> <strong>Child</strong> <strong>Check</strong>-<strong>Up</strong><br />
CPT-4 Procedure Code<br />
Immunization<br />
90698 Pentacel (DTaP-Hib-IPV-) is indicated as a primary series<br />
and first booster dose (doses 1-4) at 2, 4, 6 and 15-18<br />
months of age – Effec. 06/26/2008<br />
90700 Diphtheria, Tetanus, Acellular Pertussis (DtaP) (0yr-6yr)<br />
90702 Diphtheria, Tetanus (DT) (0yr-7yr)<br />
90707 Measles, Mumps, Rubella (MMR))<br />
90710 Measles, Mumps, Rubella, and Varicella (MMRV)<br />
vaccine, Live, for subcutaneous use (1-12 years of age) –<br />
Eff. 9/6/05<br />
90713 Poliomyelitis (IPV)<br />
90714 Tetanus, Diphtheria (Td), preservative-free – Eff. 7-1-05<br />
(7yr-999yr)<br />
90715 Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular<br />
Pertussis Vaccine, Adsorbed (Tdap) – Eff. 5-3-05<br />
(7yr-999yr)<br />
90716 Varicella (Chicken pox) vaccine (for selected recipients)<br />
90718 Tetanus and Diptheria (Td) (for adult use) (7yr-999yr)<br />
90721 Diphtheria, Tetanus, Acellular Pertussis and Hemophilus<br />
influenza type b,(DTaP-HIB) (1-5 yrs. of age)<br />
90723 Pediarix (DtaP-Hep B-IPV)<br />
90732 Pneumococcal polysaccharide virus 23 valent (Pnu 23)<br />
90733 Meningococcal Polysaccharide (MPSV4), (2-18 yr of age)<br />
– Eff. 2-10-05<br />
90734 Meningococcal Conjugate (MCV4), (11-18 yr of age) – Eff<br />
3-1-05<br />
90744 Hepatitis B vaccine (Hep B)<br />
90748 Hepatitis B and Hemophilus influenza b (Hep B-Hib) (0-18<br />
yrs of age)<br />
A.6.4<br />
ImmPRINT Immunization Provider Registry<br />
The Alabama Department of Public Health has established a statewide<br />
immunization registry. Please visit their website at https://siis.state.al.us/ for<br />
more information.<br />
A.6.5<br />
Recommended Immunization Schedule<br />
You may access the recommended immunization schedule at www.cdc.gov/nip.<br />
The schedule indicates the recommended ages for routine administration of<br />
currently licensed childhood vaccines. Combination vaccines may be used<br />
whenever any components of the combination are indicated and its other<br />
components are not contraindicated. Providers should consult the manufacturers’<br />
package inserts for detailed recommendations.<br />
A.6.6<br />
Synagis<br />
The drug Synagis must be prior authorized through Health Information Designs<br />
(HID) at 1-800-748-0130. The new form for prior authorization is available on our<br />
website at www.mediaid.alabama.gov under Programs: Pharmacy: Prior<br />
Authorizations/Override Criteria and Forms: Instruction Booklet for Form 369 and<br />
Form 351. The appropriate administration fee may be billed in addition to<br />
Synagis.<br />
A-44 January 2011
Change language