# Tetanus inj with injury..........



## nneecole (Dec 22, 2011)

Will Medicare pay for a Tetanus injection even when its an injury? I have claims that are denied. Please and thank you!


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## missy874 (Dec 22, 2011)

Yes they will pay if you are using a wound or burn dx to support the medical necessity....leave off the V code for prophylactic vaccination.


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## nneecole (Dec 22, 2011)

I am getting the Tetanus denials even with the injury code. I wonder why? Is the a different modifier I should use? When I resubmit should I do anything different? Medicare is so difficult. LOL. Thank you for your reply!


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## ChrisZim (Jan 3, 2012)

what code are you using for the tetanus?  Make sure it is not a tDap or combo vaccine code.  I think we use 90703 for just the tetanus injection long with the appropriate injury codes.  

This article may help:

http://www.familydocs.org/files/CPCodingFAQs.pdf


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## andersont (Feb 3, 2012)

*Tetanus*

Here in WA, Medicare does not cover Tetanus whether it's an accident or preventive. Fee schedule for medicare doesn't price the Tetanus vaccine codes.


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## mitchellde (Feb 3, 2012)

You need to use the V code for prophylactic use as that is the reason for the injection not the injury.  Many insurances do bot cover this.


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## kvangoor (Feb 6, 2012)

I have had luck with researching this on my local contractors website. In MI mine is WPS Medicare. I can go to their website and type in my CPT in question and the LCD and NCD's pop up for me to read. These article will give you info on what dx's Medicare will pay on if the code is covered. Otherwise I would suggest sending in an appeal. Sometimes they need notes to see the medical necessity for these.


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## Lynda Wetter (Nov 22, 2013)

mitchellde said:


> You need to use the V code for prophylactic use as that is the reason for the injection not the injury.  Many insurances do bot cover this.



Debra, Even if the injection is given at the time of an injury you say it is still apropriate to apply the V code.  Would'nt the V code be for routine purposes?


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## mitchellde (Nov 22, 2013)

A tetanus inject even when given at the time of an injury is still a prophylactic injection since the patient does not have tetanus.  You are giving to injection to prevent the condition just as you do any other prophylactic injection. Such as hepatitis you do not give because they have it, you give to prevent it.


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## lesashields@yahoo.com (Dec 31, 2013)

Per Medicare if injuries are involved they will pay for tetanus.  you will bill the injury code first then the v code.

You will bill 90471 90718 modifier 25 on E/m and modifier AT on the actual tetanus charge.

Lesa


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## chaug7 (Jun 3, 2014)

*tetanus without an injury?*

I am getting denials for annual exams with a tetanus without injury, why would they deny this?  Isn't it best to prevent the elderly from getting this? 
Any help would be appreciated.


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## Lynda Wetter (Jun 3, 2014)

I found this clip on the link below

http://www.medicareinteractive.org/page2.php?topic=counselor&page=script&script_id=1519

I would check your local MAC and see their guidelines.  Also remember the 90471 bundles with Office visits and if requirements are met it may need the 25 modifier.


***Medicare covers some vaccines and immunizations. The way Medicare covers them depends on which vaccine you need.

Your Medicare Part B will cover vaccines to prevent:
 ?Influenza (the flu);  ◦Currently, the seasonal flu shot includes both a seasonal flu shot and an H1N1 (swine flu) vaccination.

?Pneumonia; and
 ?Hepatitis B (if you are at medium to high risk).

*Part B will cover other immunizations only if you have been exposed to a dangerous virus or disease. For example, if you step on a rusty nail, Medicare will cover a tetanus shot; if you are bitten by a dog, Medicare will cover your rabies shots.* 
Note: Original Medicare covers the influenza, pneumonia, and Hepatitis B vaccines with no coinsurance or deductible if you see a provider who accepts assignment. Providers who accept assignment cannot charge you more than the Medicare approved amount. Medicare Advantage (MA) plans will cover all preventive services the same as Original Medicare. MA out-of-pocket costs for vaccines and immunizations will vary depending on the type of shot. Your costs will also vary depending on if you go to an in-network or out-of-network provider.  

All vaccines other than those for the flu, pneumonia or hepatitis B are covered under Medicare Part D. If you have a Medicare prescription drug plan (Part D), you can get coverage for any commercially available vaccine that is not covered by Part B. All Part D plans must include all commercially available vaccines on their formularies, including the vaccine for shingles (herpes zoster). Your Part D plan will pay for the vaccination itself and for your doctor or other health care provider to give you the shot (administration). Before you get a vaccination, you should check coverage rules with your Part D plan and see where you should get your shot so that it will be covered for you at the lowest cost.


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## Cynthia Hughes (Jun 3, 2014)

Medicare prices potentially-covered vaccines in the drug ASP files found at http://www.cms.gov/Medicare/Medicar...s/McrPartBDrugAvgSalesPrice/2014ASPFiles.html

90703	Tetanus vaccine, im 0.5 ML 39.026
90714	Td vaccine no prsrv >/= 7 yo, im 0.5 ML 21.154
90715	Tdap => 7 yo, im	0.5 ML 33.603

Also be sure to check the MAC for your area for specific instructions, for instance the LCD at this link includes all of the above codes as covered when an injury is the indication for the vaccination http://www.cms.gov/medicare-coverag...le&KeyWordSearchType=And&bc=gAAAABAAAAAAAA==&


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## Lynda Wetter (Jun 3, 2014)

Cynthia Hughes said:


> Medicare prices potentially-covered vaccines in the drug ASP files found at http://www.cms.gov/Medicare/Medicar...s/McrPartBDrugAvgSalesPrice/2014ASPFiles.html
> 
> 90703	Tetanus vaccine, im 0.5 ML 39.026
> 90714	Td vaccine no prsrv >/= 7 yo, im 0.5 ML 21.154
> ...



Yes this is covered when there is an injury.  However, I believe the person posting was asking if it is covered when given routinely.
If you are in the Novitas are they do require the AT modifier to be applied to the vaccine and admin charges.
_Also note this article is for Part A medicare not Part B. So this would not necessarily apply to the Office setting when providing annual care._


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## Lynda Wetter (Jun 3, 2014)

You can also do a search in the Medicare Pub100 for tetanus and see it is only covered for injuries.


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