Oncology & Hematology Coding Alert

Question: Can we report for tetanus vaccine in the absence of injury? Will Medicare pay for this?

New York Subscriber

Answer: You can get payment for Tetanus vaccine only in the event of injury. Medicare does not currently pay for the Tetanus vaccines under Part B in the absence of an illness or injury, since it is not one of the preventive vaccines statutorily covered under Part B. However, Medicare Part B does cover Tetanus or Tetanus Diptheria toxoids in the event of an injury, because, at that point, it is considered medically necessary for the treatment of the illness or injury.

The Medicare Benefit policy manual states:

“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, botulin antitoxin, antivenin sera, or immune globulin. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule.”

Turn to ABN: When the patient gets Tetanus or Td / DT vaccine in the absence of an injury, you may collect the money from the patient for the noncovered service.  Additionally, it is good practice to notify the patient in writing by having them sign an Advance Beneficiary Notice (ABN) before providing the service. Indicate on the claim the service was non-covered by appending a GY (Item or service statutorily excluded, does not meet the definition of a Medicare benefit).  You may also list the GA (Waiver of liability statement issued as required by payer policy, individual case) to the vaccine when the claim is submitted to Medicare.  The GA modifier indicates that the provider or supplier has provided an ABN to the patient. Medicare will deny such claims, and the explanation of benefits will note that the patient is responsible for payment.

Part D is an exception: Note that Medicare Part D plans generally cover vaccines that Part B does not cover. If a Medicare patient has Part D coverage, he or she may be able to get the tetanus vaccine paid by his or her Part D plan, even in the absence of an illness or injury. 

Refer: http://www.cms.gov/manuals/Downloads/bp102c15.pdf (Section 50.4.4.2 - Immunizations) and http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Vaccines-Part-D-Factsheet-ICN908764.pdf.