Billing for Tetanus Vaccine? Check the Diagnosis
Did you know that tetanus vaccines are only covered under Medicare Part B when given for treatment? Preventative tetanus vaccinations are non-covered. I found this hard to believe, so I looked it up. Sure enough, the Centers for Medicare & Medicaid Services Internet-Only Manuals Pub. 100-02, Chapter 15, Section 188.8.131.52 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 … .”
I must not be the only one who didn’t know this because Medicare Administrative Contractor (MAC) First Coast Services Option, Inc. recently posted a reminder on its website. The MAC for Florida, Puerto Rico, and the U.S. Virgin Islands, says they have “identified that many providers are submitting claims for tetanus vaccinations without the proper diagnosis codes to support the medical necessity of the service.”
To avoid documentation requests, claim processing delays, and possible denials, make sure your clinical and office staff know when the tetanus vaccination is covered under Medicare Part B and which diagnoses support the medical necessity of the service.
Injury or Exposure Code Required
The First Coast education article, posted Sept. 30, provides a few examples of ICD-10-CM codes that support coverage of a tetanus vaccination (reported with CPT® product codes 90714-90715 and admin codes 90471-90472), including:
S81.812A Laceration without foreign body, left lower leg, initial encounter
S01.511D Laceration without foreign body of lip, subsequent encounter
S41.141A Puncture wound with foreign body of right upper arm, initial encounter
S61.452A Open bite of left hand, initial encounter
S80.812D Abrasion, left lower leg, subsequent encounter
Of course, this is just a small sample; the diagnosis code just has to point to the treatment of an injury or direct exposure to a disease or condition that could develop into tetanus.
Medicare Part B does not cover most preventive immunizations including smallpox, polio, and diphtheria. Exceptions are the pneumococcal, hepatitis B, and influenza virus vaccines, which are covered when requirements are met. The COVID-19 vaccine has not yet been added to this policy, probably because the vaccine is free while the public health emergency is in force.
Know When to Use Modifier GY
If you are coding/billing for a routine preventive tetanus vaccination, First Coast recommends appending modifier GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit to the claim. The MAC will deny the claim, enabling your provider to bill a secondary payer or the patient. This is a good time to remind you about the value of the Advanced Beneficiary Notice of Noncoverage form.
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