Primary Care Coding Alert

Hint: Report appropriate diagnosis codes to avoid denials.

When your clinician administers tetanus vaccine to a patient, you will have to focus on whether or not the encounter meets coverage criteria. If coverage criteria are met, select the right vaccine code looking at type of vaccine(s) used and the age of the patient.

Choose Appropriate Code Based on Vaccine and Patient Age

When reporting an administration of tetanus vaccine, choose the appropriate code for the vaccine depending on the age of the patient that received the vaccine and on the type of vaccine used. Based on these criteria, you have ten choices to appropriately report the type of vaccine that was used on the patient:

• 90696 (Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated [DTaP-IPV], when administered to children 4 through 6 years of age, for intramuscular use)
  
• 90698 (Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated [DTaP - Hib – IPV]), for intramuscular use)
  
• 90700 (Diphtheria, tetanus toxoids, and acellular pertussis vaccine [DTaP], when administered to individuals younger than 7 years, for intramuscular use)
  
• 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)
  
• 90715 (Tetanus, diphtheria toxoids and acellular pertussis vaccine [Tdap], when administered to individuals 7 years or older, for intramuscular use)
  
• 90720 (Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine [DTP-Hib], for intramuscular use)
  
• 90721 (Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine [DTaP-Hib], for intramuscular use)
  
• 90723 (Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated [DtaP-HepB-IPV], for intramuscular use).
  

Coding tip: If only tetanus toxoid was administered to the patient, you will not have to worry about the age of the patient as you will be reporting 90703. This code does not contain any age particulars in its descriptor and can be used for any patient irrespective of their age.

Don’t Forget to Additionally Report Administration Code

While the above mentioned CPT® code choices are used to choose the type of tetanus vaccine that was administered to the patient, you will also have to report an administration code. You will choose the appropriate code for the administration based, first, on the age of the patient. When administered in young patients, you will also have to check documentation to see if counseling about the vaccine was provided to the patient or the parents of the patient by a physician or other qualified health care professional (e.g. nurse practitioner or physician assistant).

Based on the age of the patient and whether or not physician/qualified health care professional counseling was provided, you have the following CPT® code choices that you can use to report the administration of the tetanus vaccine:

• 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered)
  
• +90461 (…each additional vaccine or toxoid component administered [List separately in addition to code for primary procedure])
  
• 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid])
  
• +90472 (…each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure]).
  

Reminder: You will report the add-on codes +90461 or +90472 only in cases where other vaccines (+90472) or vaccine components (+90461) were also provided to the patient during the same visit and not as primary codes when only tetanus vaccine was administered.

Examine Coverage Criteria For Medicare Patients

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 an illness or injury.

The Medicare Benefit policy manual (chapter 15, section 50.4.4.2) 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.”

“The same section of the Medicare Benefit policy manual also states, ‘In cases where a vaccination or inoculation is excluded from coverage, related charges are also not covered.’ That means if Medicare does not cover the vaccine, it will also probably not cover its administration,” points out Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

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. 

Important: If your FP administers Tetanus or Td / DT vaccine to a Medicare patient in the absence of an injury, you may collect the money from the patient by having the patient sign an Advance Beneficiary Notice (ABN) before providing the service. But make sure to append modifier GA (Waiver of liability statement issued as required by payer policy, individual case) to the vaccine and its administration when the claim is submitted to Medicare, which 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.

Use Appropriate Diagnosis Codes to Facilitate Coverage

Your primary diagnosis should be one of the ICD-9 “V” codes indicating the need for prophylactic vaccination against bacterial diseases or combinations of diseases (e.g.,V03.7, Need for prophylactic vaccination and inoculation against bacterial diseases; tetanus toxoid alone orV06.5, Need for prophylactic vaccination and inoculation against combinations of diseases; Tetanus-diphtheria [Td] [Dt]). 

If the vaccination was prompted by an injury, you will also report an injury related ICD-9 code as the secondary diagnosis. For instance, when the injury was caused due to the patient stepping on a rusty nail, you might report 892.0 (Open wound of foot except toe[s] alone; without mention of complication) and E920.8 (Accidents caused by cutting and piercing instruments or objects; other specified cutting and piercing instruments or objects).

ICD-10: When ICD-10 codes come into effect after Oct.1, 2015, you will report Z23 (Encounter for immunization) in lieu of V03.7 and V06.5.