Billing/Coding for Tetanus with an injury

What is the best way to handle Medicare coding and billing for tetanus injection with an injury when the vaccine includes diptheria and pertusis also?

re: Billing/Coding for Tetanus with an injury

When billing for an actual incidence of injury it's covered under part B, so just go ahead and bill with the normal vaccine code for Tdap, making sure the primary diagnosis is obviously injury-related and you may need to add AT modifier as well depending on your Medicare jurisdiction.

re: Billing/Coding for Tetanus with an injury

Thank you for the informaition. I do have an additional question related to tetanus billing. When we have billed with the Tdap code we receive denials for the vaccine because they stated preventive immunizations are not covered but the code must be accurate. Should we use an ABN under those circumstances if the immunization Tdap is going to be denied. Our providers feel strongly that they should be using Tdap per CDC's recommendaiotns.

re: Billing/Coding for Tetanus with an injury

[Thank yoiu for the informaition. I do have an additional question related to tetanus billing. When we have billed with the Tdap code we receive denials for the vaccine because they stated preventive immunizations are not covered but the code must be accurate. Should we use an ABN under those circumstances if the immunization Tdap is going to be denied. Our providers feel strongly that they should be using Tdap per CDC's recommendaiotns. ]

Medicare does follow the CDC recommendations but different jurisdictions tend to apply those recommendations at different times, so just in case your particular jurisdiction has not updated its policy yet, I would say yes to the ABN with an explanation to the patient that there is a chance they will be billed for the vaccine, but the charges are fully reimbursable to the patient if submitted to Medicare Part D. It's just not possible for providers to bill Part D themselves. Alternatively, if the patient is unable to pay temporarily, pharmacies can bill Part D directly so if necessary the Dr. can prescribe the vaccine and the patient can have it administered at a pharmacy in many cases.

It is also possible that your jurisdiction will only offer partial payment (for the tetanus part of the vaccine, since that is related to the injury, but withhold the rest of the payment due to diphtheria/pertussis being considered unrelated in instance of injury). This is most likely changed/about to change though due to the CDC recommendations.

This is one of those tricky things where the coding has to be "just so" to pass automatic Medicare edits and those edits do vary by region. It may take some experimenting on your part to get a claim paid, but once you do at least you'll know the exact requirements. Sorry I can't be more specific, the variability by region for vaccines is simply more extreme than with other policies.

It would also be a good idea to check LCD's for your MAC on this if you haven't already done so.