© Copyright 2025 American Medical Association. All rights reserved.
The CPT® Code 96381 refers to the administration of a seasonal dose of respiratory syncytial virus (RSV) monoclonal antibody via intramuscular injection. This procedure involves delivering a vaccine that contains laboratory-produced proteins designed to mimic the immune response against the RSV virus, which is known to cause severe respiratory infections, particularly in infants and young children. The administration is typically performed as a single intramuscular injection into the anterolateral thigh, a common site for such vaccinations. This procedure is crucial for infants and neonates entering their first RSV season, as well as for young children under the age of two who remain highly susceptible to the virus. The timing of the administration is generally scheduled for October or November, aligning with the onset of the RSV season to provide optimal protection. Additionally, it is important to note that the administration of this vaccine may include face-to-face counseling provided by a physician or qualified healthcare professional to the patient’s family or caregiver, as indicated by the related code 96380.
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The administration of the respiratory syncytial virus (RSV) monoclonal antibody is indicated for specific patient populations who are at high risk for severe RSV disease. The following conditions warrant the use of this procedure:
The procedure for administering the RSV monoclonal antibody involves several key steps to ensure proper delivery and patient safety. Each step is critical to the successful administration of the vaccine:
Post-procedure care following the administration of the RSV monoclonal antibody includes monitoring the patient for any immediate side effects or allergic reactions. Patients may experience mild side effects such as soreness at the injection site, low-grade fever, or irritability, which typically resolve on their own. Parents or caregivers are advised to observe the patient for any unusual symptoms and to contact a healthcare provider if they have concerns. Additionally, follow-up appointments may be scheduled to assess the patient's response to the vaccine and to discuss any further vaccinations or health considerations as the RSV season progresses.
| Short Descr | ADMN RSV MONOC ANTB IM NJX | Medium Descr | ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX | Long Descr | Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Items and Services Not Billable to the MAC | Berenson-Eggers TOS (BETOS) | none | MUE | 1 |
| 96 | Habilitative services: when a service or procedure that may be either habilitative or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified health care professional may add modifier 96 to the service or procedure code to indicate that the service or procedure provided was a habilitative service. habilitative services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep and/or improve those learned skills. habilitative services also help an individual keep, learn, or improve skills and functioning for daily living. | GA | Waiver of liability statement issued as required by payer policy, individual case | GW | Service not related to the hospice patient's terminal condition | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GZ | Item or service expected to be denied as not reasonable and necessary | SL | State supplied vaccine |