Medicare Part B & Tetanus Vaccines
Did you know that Medicare Part B only covers a tetanus vaccine when it’s given as the result of an injury or direct exposure? Medicare Part B does not cover tetanus vaccines when given preventatively. In fact, Medicare Part B doesn’t cover most preventative vaccines, so coding is important to avoid claims processing delays and possible denials.
An article by the Medicare Administrative Contractor (MAC) First Coast Service Options, Inc lists several examples of diagnosis codes that support the medical necessity of the vaccine. These examples include, but are not limited to:
- 812A (laceration without foreign body, left lower leg – initial encounter)
- 141A (puncture wound with foreign body of right upper arm – initial encounter)
- 82D (abrasion, left lower leg – subsequent encounter)
The claims must be coded to the highest level of specificity and should be well documented in the patient’s office notes, including the part of the body that was injured. If the claim is billed with an inappropriate diagnosis code, the claim will deny for medical necessity. When routine tetanus vaccines are provided, append a “GY” modifier. This indicates that the “Item or service statutorily excluded or Does not meet the definition of any Medicare benefit.” Lines with this modifier, will be denied by Medicare Part B but can be billed to a secondary or the patient.
As a reminder, below are the appropriate codes for billing a tetanus vaccine:
| CPT® Code | Descriptor |
| 90714 | Tetanus and diphtheria toxoids, older than 7 |
| 90715 | Tetanus, diphtheria toxoids and acellular pertussis vaccine, older than 7 |
| 90471 | Immunization administration |
| 90472 | Immunization administration (ea. additional vaccine) |
Resources:
https://medicare.fcso.com/Billing_news/0422983.asp
https://www.aapc.com/blog/86567-billing-for-tetanus-vaccine-check-the-diagnosis/
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