Pulmonology Coding Alert

Question: Our facility administered Tdap vaccine to a few Medicare patients. These patients did not sign an ABN. Is the vaccine covered under Part B or Part D? If this is a Part D immunization, how can our office get reimbursed from the patients who have been administered the vaccine?

New York Subscriber

Answer: CMS classifies all vaccinations under Part B or Part D. Medicare Part B provides vaccine reimbursement for Medicare patients when it is termed as medically necessary. Medicare Part B does not provide any reimbursement for vaccines that are classified under Part D.

Tdap vaccine is a vaccine that is provided for the prevention of pertussis (whooping cough). This is a vaccine that comes under Part D, and it should be obtained by a Medicare Part D network pharmacy without out-of-pocket costs by the beneficiary. It may also be provided in a network provider's office; however, this would require the beneficiary to pay for the vaccine costs up front and then be reimbursed by their Medicare Part D plan. The beneficiary should contact their Medicare Part D plan for advanced reimbursement instructions.

ABNs are not required for care that is statutorily excluded or for services that are never a Medicare benefit. Routine vaccines (with the exception influenza, pneumococcal and Hepatitis B) are considered program exclusions. However, physicians can issue an ABN voluntarily to ensure that the beneficiary knows his/her financial obligations. These claims can be submitted to Medicare with modifier GX (notice of liability issued, voluntary under payer policy)

Some Tips about ABN Completion:

Proper delivery of the ABN includes:

• Delivered (preferably in person) and comprehended by a suitable recipient;
• The approved, standardized ABN with all required blanks completed;
• Provided far enough in advance of potentially non-covered items or services to allow sufficient time for the beneficiary to consider all available options;
• Explained in its entirety and all questions related to the ABN are answered; and
• Signed and dated by the beneficiary or his/her representative after he/she has selected one option box on the notice.

The approptiate ABN option should be selected and marked by the patient and signed. If you select the option on behalf of the patient, then the document becomes invalid and will be deemed as coerced into filling the form.

If the patient does not comply to fill the ABN, then the physician has to document this and then has to sign in addition to having another witness sign the form. This can then be legally binding for the patient to pay for the service that has been rendered (but not covered by Medicare).