Get familiar with Medicare's rules from medical necessity to choice of products.
Medicare's tetanus injection coverage riddle boils down to one issue: Is there an injury?
Anticipate Coverage for Injury Treatment
When the answer is, "Yes, the patient needed a tetanus injection to treat a wound," you've hit coverage criteria. "Medicare will not pay for tetanus shots given to Medicare patients unless there is a current injury diagnosis reported," according to Lisa Curtis, CPC, CEMC, of Boulder Medical Center in Colorado.
Tip: Any wound that causes a break in the skin potentially will need 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 skin abrasions.
Show Covered With 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 with 90703 (tetanus toxoid only) or 90702, 90714, or 90718 (tetanus toxoid in combination with diphtheria toxoid), you'll need two ICD- 9 codes, relates Rebecca Woodward, CPC, CEMC, of MedVentures LLC in High Point, N.C. 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: A nurse administers tetanus toxoid to a patient who suffered minor injuries after stumbling and getting pricked in the neck with small shards of wood. Code this encounter's diagnoses as:
• V03.7 -- Need for prophylactic vaccination and inoculation against bacterial diseases : Tetanus toxoid alone
• 910.6 -- Superficial injury of face, neck, and scalp except eye; superficial foreign body (splinter) without major open wound and without mention of infection.
Use Matching Product Code, Plus Administration
For allowed vaccine and vaccine associated charges, report the CPT code for the product that staff administered. Make sure the CPT code description exactly matches the vaccine's components. The following CPT codes represent different formulations of the tetanus toxoid or tetanus-diphtheria combination:
• 90702 -- Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals younger than 7 years, for intramuscular use
• 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 -- Tetanus and diphtheria toxoids (Td) adsorbed 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. For instance, if a nurse administers DTaP (diphtheria-tetanus-acellular pertussis), you should not use a Td or DT combination CPT code to claim reimbursement.
Instead, use the CPT code that correctly describes the complete combination given. For DTaP, you would use 90700 (Diphtheria, tetanus toxoids, and acellular pertussis vaccine [DTaP], when administered to individuals younger than 7 years, for intramuscular use). 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. For vaccine administration to a patient eight years of age and younger when the physician counsels the patient/family, you'll use 90465 or +90466. For older patients or encounters without physician counseling, assign 90471 or +90472 depending on number of injections given.
Don't miss: When a vaccination is excluded from coverage, your Medicare contractor will not cover any related charges. For example, Medicare will not cover the immunization administration (90471, +90472, Immunization administration ...) if the vaccine is not covered. When a vaccination is excluded from coverage, the entire charge will be denied -- including office visits primarily for administering a non-covered injection.
Absent Wound Assume Noncoverage
When administered as a preventive vaccine, Medicare does not cover a tetanus shot. "In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered," according to the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.4.2.
Example: A Medicare beneficiary who's apparently well requests a tetanus booster shot, since he had his last one more than ten years ago. In this scenario, Medicare does not cover the tetanus vaccination or inoculation. This includes shots for tetanus antitoxins and tetanus booster vaccines.
Secure ABN for Preventives
Avoid having to foot preventive tetanus vaccine administration by informing the patient of noncoverage. If you believe Medicare considers the tetanus injection "not medically necessary," have the patient sign an advance beneficiary notice (ABN). You need such a form in the patient's chart in order to bill the patient.
Without a signed ABN, Medicare assumes that the patient did not know the vaccination was not covered.
Therefore, your practice would have to write off the charge as "not a covered benefit."
