Billing for Tetanus Vaccine? Check the Diagnosis


Did you know that tetanus vaccines are covered under Medicare Part B only when administered for treatment purposes? Preventive tetanus vaccinations do not fall under coverage. The Centers for Medicare & Medicaid Services Internet-Only Manuals Pub. 100-02, Chapter 15, Section clarifies, “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….”

A recent reminder posted on the website of the Medicare Administrative Contractor (MAC) responsible for Florida and the U.S. Virgin Islands highlights that numerous providers have been submitting claims for tetanus vaccinations without appropriate diagnosis codes to substantiate the medical necessity of the service.

To steer clear of requests for documentation, delays in claim processing, and potential denials, it is vital to ensure your clinical and administrative staff understand when the tetanus vaccination qualifies for Medicare Part B coverage and which diagnoses corroborate the medical necessity of the service.

Inclusion of an Injury or Exposure Code is Essential

In a September 30 educational article by First Coast, a few instances of ICD-10-CM codes that validate the coverage of a tetanus vaccination (to be reported with CPT® product codes 90714-90715 and administration codes 90471-90472) are provided. These examples include:

  1. S81.812A: Laceration without foreign body, left lower leg, initial encounter
  2. S01.511D: Laceration without foreign body of lip, subsequent encounter
  3. S41.141A: Puncture wound with foreign body of right upper arm, initial encounter
  4. S61.452A: Open bite of left hand, initial encounter
  5. S80.812D: Abrasion, left lower leg, subsequent encounter

However, this is merely a small selection; the diagnosis code must essentially pertain to the treatment of an injury or direct exposure to a disease or condition that could lead to tetanus.

Medicare Part B generally excludes coverage for most preventive immunizations, including smallpox, polio, and diphtheria. Exceptions encompass the pneumococcal, hepatitis B, and influenza virus vaccines, which are covered when the requisite criteria are met. The COVID-19 vaccine has not yet been incorporated into this policy, likely due to its availability as a no-cost option during the prevailing public health emergency.

Understanding the Appropriate Use of Modifier GY

If you are coding or 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 issue a denial for the claim, allowing your provider to bill a secondary payer or the patient. This serves as a valuable reminder about the significance of the Advanced Beneficiary Notice of Noncoverage form.”

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