Internal Medicine Coding Alert

Medicare isn't a big fan of reimbursing tetanus vaccines, but there are exceptions.

Think getting Medicare to pay for tetanus shots is like taking a shot in the dark?

The medical necessity for providing a tetanus shot can unlock coverage. Here are a few easy-to-follow steps to sharpen your tetanus coding, and obtain the reimbursement you deserve.

If the patient needs only a booster shot of his tetanus vaccine, unrelated to injury or illness, it is not covered under Medicare Part B. The Medicare Benefit Policy Manual, Chapter 15, Section 50.4.4.2, states that vaccinations or inoculations are excluded as immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, including tetanus antitoxin.

The tetanus vaccine is covered, however, for vaccines administered for prevention of an illness. The vaccine not covered under Medicare Part B would be covered under Part D, says Rebecca Marthaller, director of Lower Colombia Medical Billing in Long View, Wash.

When a vaccination is excluded from coverage, any related charges are also not covered. Medicare will not cover the immunization administration (90471-90472,Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections] ...). When a vaccination is excluded from coverage, the entire charge will be denied -- including office visits primarily for the purpose of administering a non-covered injection.

Clue: Not sure of the reason for the tetanus shot? Look at the diagnosis code. If you're using V06.5 (Need for prophylactic vaccination and inoculation against combinations of diseases; tetanus-diphtheria [Td] [DT]) for preventive vaccination, then Medicare will not cover the immunization. Medicare defines a preventive vaccine as a routine booster every 10 years throughout life for patients 7 years of age or older who have received a primary series of tetanus- and diphtheria-containing vaccine.

Don't submit a claim to Medicare if your internist's service is for a routine immunization update. To obtain a denial for secondary insurance purposes, or if the beneficiary requests a denial, submit the claim and append modifier GY (Noncovered service) to the code, provided you have obtained an advance beneficiary notice -- your only way to get payment (see "Use ABNs to Get Payment for Tetanus Vaccinations" on page 67).

Medicare Part B covers tetanus toxoid vaccines when they are directly related to the treatment of an injury. To realize payment, you'll need a proper diagnosis code, says Catherine Brink, BS, CMM, CPC, CMSCS, president of Healthcare Resource Management in Spring Lake, N.J. Use diagnosis code V03.7 (Need for prophylactic vaccination and inoculation against bacterial diseases, Tetanus toxoid alone) for tetanus shots administered for wound care. Use this in conjunction with the appropriate ICD-9 for open wounds (870"897), superficial wounds (910"919), or 959 (Injury, other and unspecified).

Example: If a patient needs a tetanus vaccination related to an accidental puncture wound -- for example, 919.6 (Superficial foreign body [splinter] without major open wound and without mention of infection) -- it is covered under Part B.

The vaccines listed below are eligible for payment from Medicare. These may be reimbursed regardless of the setting where they are provided. The administration fee for these vaccines is also eligible for payment. Tetanus injections are covered when given for an acute injury to a person who is insufficiently immunized. The eligible product codes for such an injection are:

• 90703 -- Tetanus toxoid adsorbed, for intramuscular use

• 90714 -- Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when administered to individuals 7 years or older, for intramuscular use

• 90718 -- ...when administered to individuals 7 years or older, for intramuscular use.

Choose your vaccine code based on why the patient is receiving a tetanus shot. Then choose the appropriate product code that exactly matches the vaccine's components. For instance, if the injection included diphtheria, rather than just tetanus, look to 90714 and 90718, instead of 90703. For the regular product, use 90718. If you're using preservative-free Td (DECAVAC), use 90714.

To report the administration of these vaccines, the product codes must be used in addition to an immunization administration code (90471 or 90472, Immunization administration ...).

Example: The American College of Physicians gives this coding example. A diabetic man steps on a rusty nail, causing an uncomplicated open wound in his foot that does