Medicare Immunizations and Modifiers????

[Lindsey_McBee]

Here are my two questions/scenarios:
1. Medicare patient receives Adacel (90715) with a diagnosis of medical necessity (direct exposure).
2. Medicare patient receives Adacel with a preventive diagnosis.
In situation 2. would the clinic be required to obtain an ABN? Also, If an ABN was not obtained, would the clinic be able to bill the patient?
I have heard a lot of conflicting information regarding this. I spoke to a Medicare rep and she said that Adacel is a covered CPT code and that the reason it would be denied would be due to the diagnosis code, thus we would be responsible for obtaining the ABN prior to administering the shot.
Please advise

[Lisa Bledsoe]

I don't believe Adacel is a covered vaccine for Medicare even if there is an approved dx code (for Tetanus or Tetanus and Diptheria). Because Adacel (90715) includes acellular pertussis, I'm failry certain CMS does not pay for it...at least our carrier (Trailblazer) does not. They will only pay for 90703, 90714 or 90718 with an injury dx. As for the ABN, I don't believe it is necessary, but would check your carrier and the CMS websites for validation.

[lnaschke]

If after review of your National Code Determination and Local Code Determination, the service is specified as "not medically necessary" then you must have a signed ABN in the patients chart in order to bill the patient. Otherwise, your practice would have to write off the charge as "not a covered benefit."

Hope this is helpful
Laura

[jcarlso3]

Hello,
i am stumped because i have a patient that for her visit she was given a TD shot; and office coded it as 90700. Which was invalid for the person since she was over 7 shouldn't the correct code be 90715? I thought that the cpt code 90718 would in fact be used like for a person who got stuck with a rusty nail or something to that effect. thank you for your help.

[mhadsell]

90715 and 90718 are not the same drug. Medicare should cover a 90718 Td if the patient has a wound. Otherwise, obtain an ABN. Medicare does not cover a 90715 Tdap, even if there is a wound. Again, obtain an ABN.

[Lisa Bledsoe]

Here is the link to Trailblazers LCD. 90715 is not on the list as one of the tetanus codes approved. My understanding that it is not covered or approved is because it contains pertussis and costs more. According to the CDC pertussis is recommended for patients under 65.
http://www.trailblazerhealth.com/Too...spx?DomainID=1