Medicare Compliance & Reimbursement

Tip: Prove medical necessity rather than preventive service.

If you have been puzzling over whether or not Medicare reimburses tetanus shots, you are not alone. Here’s the lowdown on when you can expect to be paid and when your claim will be rejected.

When administered as a preventive vaccine, Medicare does not cover a tetanus shot. However, if the patient needs a tetanus injection to treat a wound, you’ve hit coverage criteria. “Tetanus shots that don’t contain pertussis (whooping cough) are covered by Medicare Part B only when you’ve been injured or directly exposed to something that can cause tetanus,” the Centers for Medicare & Medicaid Services (CMS) says on its website.

Tip: Any wound that causes a break in the skin potentially qualifies for a tetanus shot. “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, such as anti-rabies treatment, tetanus antitoxin or booster vaccine ...” according to the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.4.2.

Examples of cases that will require tetanus vaccination include:

• patients who suffer from a deep or puncture wound
• wounds contaminated with dirt
• burn injuries
• chemical burns
• painful pen skin abrasions.

Show Wound Diagnosis

As appropriate, use an injury-related ICD-9 code to indicate that the vaccine was given for a medically necessary reason rather than as a preventive service. When filing claims for the toxoid product, you’ll need two ICD-9 codes. The primary diagnosis should be one of the ICD-9 V codes that indicates the need for prophylactic vaccination against bacterial diseases or combinations of diseases (V03.7, Tetanus toxoid alone or V06.5, Tetanus-diphtheria). Report an injury-related ICD-9 code as the secondary diagnosis.

Example: You administer tetanus toxoid to a patient who suffered minor injuries after stumbling and cutting her hand on the side of a metal and wooden desk. Code this encounter’s diagnoses as:

• V03.7 — Need for prophylactic vaccination ... Tetanus toxoid alone
• 910.6 — Superficial injury of face, neck, and scalp except eye; superficial foreign body (splinter) of face neck and scalp except eye without major open wound and without mention of infection.

Use Matching Product Code

For allowed vaccine and vaccine associated charges, report the CPT® code for the product that staff administered. The following CPT® codes represent different formulations of the tetanus toxoid or tetanus-diphtheria combination:

• 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.

Warning: If staff used a different product, do not try to use one of the codes above. Instead, use the CPT® code that correctly describes the complete combination given. If you use CPT® codes that are inconsistent with your medical record documentation, on audit you may be liable for fraud.

Also, don’t forget to bill the appropriate administration code in addition to the vaccine product code. Choose the immunization administration code based on the patient’s age and physician counseling.

Don’t miss: Deductibles do apply to tetanus shots following an injury, CMS notes on its website. Beneficiaries “pay 20 percent of the Medicare-approved amount for the shot if the doctor or other qualified health care provider accepts assignment for giving the shot,” the agency notes. Copayments apply for tetanus shots administered in the hospital outpatient setting.