Primary Care Coding Alert

Question: Does Medicare cover Tetanus when it is administered to a patient without a documented injury?

Maryland Subscriber

Answer: When filing claims for tetanus vaccine administration, you first need to report the code for the vaccine itself. There are currently ten CPT® codes that describe tetanus vaccine, either alone or in combination with other vaccines:

• 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 [DtaPHepB-IPV], for intramuscular use).
  

You also want to report a code for the administration of the vaccine. Choose an appropriate code(s) from 90460-+90461 or 90471, depending on the age of the patient and whether or not counseling by a physician or other qualified health care profession was involved. 

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 or V06.5, Need for prophylactic vaccination and inoculation against combinations of diseases; Tetanus-diphtheria [Td] [Dt]). If the vaccination was prompted by an injury (e.g. the patient stepped on a rusty nail), you will also report an injury related ICD-9 code as the secondary diagnosis. 

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 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.”

If your FP administers Tetanus or Td / DT vaccine to a 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 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.

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 .