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How do we get paid for a tetanus shot for a Medicare patient?


Medicare does not currently pay for the Tetanus vaccines as they consider it preventive and it doesn’t happen to be one of the preventive services they cover. However, the program does cover Tetanus or Tetanus Diptheria toxoids, but only in the event of an injury.

The Medicare Benefit policy manual 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, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule.'

Refer: http://www.cms.gov/manuals/Downloads/bp102c15.pdf (Section 50.4.4.2 - Immunizations)

Instructions to be followed to receive payments for Tetanus vaccines

When filing claims with CPT codes 90702, 90703, 90714, or 90718, the primary diagnosis should be one of the ICD-9 "V" codes indicating the need for prophylactic vaccination against bacterial diseases or combinations of diseases (V03.7 Tetanus toxoid alone or V06.5 tetanus-diphtheria [Td] [DT]) plus an injury related ICD-9 code as the secondary diagnosis.

If Tetanus or Td / DT vaccines is administered to a patient physicans may collect the money from the patient by giving an Advance Beneficiary Notice (ABN). But make sure to append Modifier GA to the vaccine when the claim is submitted to Medicare, which indicates that the provider or supplier has provided an Advance Beneficiary Notice (ABN) to the patient. Medicare will deny such claims and the explanation of benefits will note that the patient is responsible for payment.


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