Billing CPT Code 90714

kaylaholden

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Hello!

We are getting a lot of denials for the CPT code 90714 from Medicare. We have tried every which way possible to have them cover the charges. IE: a patient comes in for a dog bite on left forearm. We code ICD 10/CPT as follows:

1. Puncture Wound: S51.832A
2. Dog Bite : W540XXA


1. E/M 99203-25 OR 99213-25
2. Tetanus- 90714
3. Immunization- 90471-59

If anyone can help me out and let me know how you get Medicare to cover this fee, I would greatly appreciate it!
Thanks :)
 
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The LCD for my local MAC states:
"The following immunizations are covered post-exposure:

Tetanus, Diphtheria and Pertussis (Tdap) Vaccines and Tetanus Diphtheria (Td) Vaccines

These injections are covered when given for an acute injury to a person who is incompletely immunized.

1. Recommendations on tetanus prophylaxis are based on the condition of the wound and the patient's immunization history.

a. For more serious wounds, toxoid should be administered if the patient has not had a booster dose within the past 5 years.

b. A wound with any of the following clinical features is a tetanus-prone wound: more than 6 hours old; stellate; avulsion; abrasion; greater than 1 cm deep; injury due to missile, crush, burn, or frostbite; signs of infection; devitalized tissue; or a wound which affords anaerobic conditions or which has been incurred in a circumstance with probability of exposure to tetanus spores.

c. In cases of clean, minor wounds, tetanus toxoid should be administered only if the patient has not had a booster dose within the past 10 years.


2. When a patient has not received primary immunization or the primary immunization status is not known, and the patient has sustained a high-risk wound, administration of Tdap is recommended. Administration of Td may be appropriate based on the time since the patient received their last Tdap and the severity of the wound.

3. When a tetanus booster is given to a patient in the absence of an injury/potential exposure, the injection does not meet the coverage criteria for Medicare (even though it may be appropriate preventative treatment). Preventative services should not be billed to Medicare."

.... "Documentation Requirements
Documentation supporting the medical necessity of this item, such as diagnosis codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary.

Documentation in the progress notes must identify the exposure, describe the wound, describe the immunization status of the patient, and be available if requested. "

"... covered when:
- There has been direct exposure of the associated disease to the patient, and
- There is significant risk that the patient could contract the disease as a result of the exposure."
 

thomas7331

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One thing to note is that some immunizations that aren't covered under patients' Medicare Part B benefit may be covered under their Part D pharmacy benefit.
 

kaylaholden

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The LCD for my local MAC states:
"The following immunizations are covered post-exposure:

Tetanus, Diphtheria and Pertussis (Tdap) Vaccines and Tetanus Diphtheria (Td) Vaccines

These injections are covered when given for an acute injury to a person who is incompletely immunized.

1. Recommendations on tetanus prophylaxis are based on the condition of the wound and the patient's immunization history.

a. For more serious wounds, toxoid should be administered if the patient has not had a booster dose within the past 5 years.

b. A wound with any of the following clinical features is a tetanus-prone wound: more than 6 hours old; stellate; avulsion; abrasion; greater than 1 cm deep; injury due to missile, crush, burn, or frostbite; signs of infection; devitalized tissue; or a wound which affords anaerobic conditions or which has been incurred in a circumstance with probability of exposure to tetanus spores.

c. In cases of clean, minor wounds, tetanus toxoid should be administered only if the patient has not had a booster dose within the past 10 years.


2. When a patient has not received primary immunization or the primary immunization status is not known, and the patient has sustained a high-risk wound, administration of Tdap is recommended. Administration of Td may be appropriate based on the time since the patient received their last Tdap and the severity of the wound.

3. When a tetanus booster is given to a patient in the absence of an injury/potential exposure, the injection does not meet the coverage criteria for Medicare (even though it may be appropriate preventative treatment). Preventative services should not be billed to Medicare."

.... "Documentation Requirements
Documentation supporting the medical necessity of this item, such as diagnosis codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary.

Documentation in the progress notes must identify the exposure, describe the wound, describe the immunization status of the patient, and be available if requested. "

"... covered when:
- There has been direct exposure of the associated disease to the patient, and
- There is significant risk that the patient could contract the disease as a result of the exposure."

Thank you, however, This is information that we already know, we are just having trouble with the denials. Why is it being denied? How can we stop it from being denied? Is the Tetanus not a covered charge for Medicare. We cant get Medicare to answer any of our questions.. so basically, how do we bill it for Medicare to approve.
 

vickynelu

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Hello!

We are getting a lot of denials for the CPT code 90714 from Medicare. We have tried every which way possible to have them cover the charges. IE: a patient comes in for a dog bite on left forearm. We code ICD 10/CPT as follows:

1. Puncture Wound: S51.832A
2. Dog Bite : W540XXA


1. E/M 99203-25 OR 99213-25
2. Tetanus- 90714
3. Immunization- 90471-59

If anyone can help me out and let me know how you get Medicare to cover this fee, I would greatly appreciate it!
Thanks :)


Hello, Why use modifier 59 to 90471?
 

vickynelu

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Why using modifier 59 to 90471?

I guess you get paid for the visit and administration of the drug. Medicare patients should file with their Part D for the drug reimbursement.

What is the denial?

Vicky D CPC-P
 
Last edited:

jemery

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Medicare and Immunizations

Medicare will cover CPT 90714, but it will NOT cover the immunization with an office visit. What our clinic normally does is treat the wound, and have the patient stop at Walgreens, CVS, etc on their way home to receive the TDAP vaccine under their Part D benefits. Or we have the patient return the next day for the immunization and charge that visit as only the vaccine administration and TDAP even if we did a dressing change.
 

sgregoire

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Cpc

Me again, replying to my own post, because I couldn't edit it. I wanted to quote from the, "Overview of ICD10 Official Conventions," page viii, " 'Punctuation' ( ) parentheses are used in both the index and tabular list to enclose nonessential modifiers; supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned." Feedback is much appreciated.
 

taperkins

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Hello!

We are getting a lot of denials for the CPT code 90714 from Medicare. We have tried every which way possible to have them cover the charges. IE: a patient comes in for a dog bite on left forearm. We code ICD 10/CPT as follows:

1. Puncture Wound: S51.832A
2. Dog Bite : W540XXA


1. E/M 99203-25 OR 99213-25
2. Tetanus- 90714
3. Immunization- 90471-59

If anyone can help me out and let me know how you get Medicare to cover this fee, I would greatly appreciate it!
Thanks :)
See attached. Novitas Solutions directs providers to apply modifier AT for payment consideration.
 

Attachments

hollomanh

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Because 90714 has the d/a/p portion along with the tetanus, Medicare will consider it for payment when given for an appropriate open wound or such (see above NCD listing), but it will not pass thru their edits and pay even if you have a perfectly valid wound or laceration DX code. In order to get your claim considered for payment, you will need to send a redetermination with notes to see if they will reconsider the PR denial. Unfortunately, because we have tons of urgent and primary care, we do this often. The providers do not wish to send the patient away from their office without treating them completely, so sending them to the pharmacy to get the vaccine was not something they wanted to consider. And CDC recommends getting the 90714 or even the 90715 in most of these cases because of "catch up" and such.

As to the use of modifier AT as someone mentioned above, I don't believe it is appropriate. Per our contractor Palmetto, this is for acute treatment (chiropractic) and is only to be used with 98940, 98941, and 98942.

I am also unsure of why you'd use a modifier -59 on 90471 since you already have your modifier -25 on the E&M. But I'd imagine your denial that comes thru pays the E&M, pays the 90471, and denies the 90714 with a PR-49 denial. They may deny the 90471 as the same PR-49 if their systems are smart enough. Palmetto's is not.
 

EileenC

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Getting Medicare to pay for tetanus

Hi. So Medicare will pay for tetanus shot (90714 pr 90715) with modifier AT added (acute treatment). Also attach AT modifier to 90471 code. In my experience, Medicare will pay for an office visit with modifier 25 along with the tetanus shot and admin code. They will not pay a visit code with a laceration repair code with the same dx. There is no need for modifier 59 on any of these codes.
 

EileenC

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Medicare paying tetanus

Forgot to mention. Modifier AT is appropriate as the tx is acute. I bill primary care and urgent care and have no issues getting these paid.
 
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Use AT Modifier

Add an AT modifier to 90714. This is the only way that our primary care clinic will receive reimbursement from Medicare on this.
I don't feel comfortable using The AT Modifier in this situation. (AT Acute treatment (chiropractic claims) - This modifier should be used when reporting CPT codes 98940, 98941, 98942 or 98943 for acute treatment.)
 

kaylaholden

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Hi. So Medicare will pay for tetanus shot (90714 pr 90715) with modifier AT added (acute treatment). Also attach AT modifier to 90471 code. In my experience, Medicare will pay for an office visit with modifier 25 along with the tetanus shot and admin code. They will not pay a visit code with a laceration repair code with the same dx. There is no need for modifier 59 on any of these codes.
Medicare does NOT pay with the modifier AT. We have tried that.
 
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Location
Glenside, PA
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Hello!

We are getting a lot of denials for the CPT code 90714 from Medicare. We have tried every which way possible to have them cover the charges. IE: a patient comes in for a dog bite on left forearm. We code ICD 10/CPT as follows:

1. Puncture Wound: S51.832A
2. Dog Bite : W540XXA


1. E/M 99203-25 OR 99213-25
2. Tetanus- 90714
3. Immunization- 90471-59

If anyone can help me out and let me know how you get Medicare to cover this fee, I would greatly appreciate it!
Thanks :)
Here is my thinking.... Sometimes Medicare has to be hand fed...don't include the dog bite code on the injection. The -59 modifier is also inappropriate. If read your rejection codes carefully...if Medicare kicked out one, is it possible they didn't pay the other because the first kicked out? My docs got so fed up with this conundrum that they stopped giving tetanus to anyone. They sent them to the CVS.
992X3-25 1,2
90714 1
90471 1

If you were just billing the latter two codes with the 2nd dx, it may kick out for not meeting the LCD's requirement for medical necessity.
 
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This is how I would of billed this claim on the 99213 add modifier 25 with your diagnosis and on the vaccine 90714 add mod 59 with diagnosis Z23 and on admin 90471 add mod 59 with the diagnosis z23 as well , and hopefully it will pay your claim I never had any problem getting my claim pay.
 

mamon

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We had a denial like this. We appended modifier AT to both vaccine and admin codes, and also sent out the visit notes to support the medical necessity of the procedure. Medicare paid for them.

"When billing the tetanus vaccine for treatment of an injury or direct exposure to a disease or condition, append modifier AT (acute treatment) to both the vaccine code and administration code. The medical record must support the need for the service; include a specific body part where the injury occurred, and the use of modifier AT."

Tetanus Vaccine under Part B
 
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