# Medicare reimbursement for the TDAP vaccine



## rhavard (May 30, 2018)

Would someone please verify if Medicare is reimbursing for the TDAP vaccine? From what I have read on CMS, they will only cover it for medically necessary reasons, not for prevention. Says the Part D will cover the drug, but will Medicare cover the administration fee for giving the shot? Any help is greatly appreciated!


----------



## jhendrix08 (May 30, 2018)

Yes, they will cover the drug and administration but ONLY if the patient has Medicare part D coverage.  Hope that helps!


----------



## rhavard (Jun 2, 2018)

Thank you, that does help.


----------



## Misdavis (Nov 6, 2018)

*I know this thread is super old but...HELP*



jhendrix08 said:


> Yes, they will cover the drug and administration but ONLY if the patient has Medicare part D coverage.  Hope that helps!



I have been battling this issue for a WHILE now.. So we have only been denied for the tdap vaccine even when there is an injury. CMS Reg. 50.4.4.2 states that the tetanus antitoxin and tetanus booster are covered under part B with an injury. Noridian spells it out in plain English that it is covered (with an injury) but only covered by part D as preventative.

Palmetto doesn't spell it out like this at all. They have 0 guidance and the only reference that they do have is the fee schedule which has a rate of 0 for the rvu and payment amount with an indicator of 9. so I reached out to Palmetto and the rep told me that tdap WAS a covered service that it had to be an injury and documentation to support had to be submitted. I said it has and it was still yet denied. Their suggestion was to do a level 1 appeal and reference the above CMS regulation. This is where I am. 

Does anyone have any information on this? Have any successes in receiving payment from Part B for Tdap? Why does the fee schedule have it as an "excluded" service and then the regs have it payable with injury? Any help or advice would really appreciated. This is a headache that just won't go away. 

Thanks!!


----------



## erjones147 (Nov 7, 2018)

Our MAC is Novitas, and we have to submit with a modifier -AT. I've only seen a Medicare TDAP for injury reasons twice in 5 years, so I can't remember anything else that is specifically needed


----------

