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Last Modified: 6/13/2019 Location: FL, PR, USVI Business: Part A, Part B

Avoid claim processing delays when billing tetanus vaccinations

First Coast Service Options (First Coast) has identified that many providers are submitting claims for tetanus vaccinations without the proper diagnosis codes to support the medical necessity of the service. This incomplete claim information causes claim processing delays as First Coast must send additional documentation requests to verify appropriate payment of the service.
Our goal is to reduce your burden by reminding providers of Medicare’s coverage guidelines and billing requirements for tetanus vaccinations.
Coverage guidelines
Tetanus vaccinations are eligible for Medicare Part B coverage only when given as part of a therapeutic treatment of an injury. To avoid denials and expedite payment, providers must verify that claims submitted to Medicare include the proper procedure and diagnosis codes to support the medical necessity for the vaccination.
Claims must be coded to the highest level of specificity, with related documentation supporting what’s been billed (i.e., specific body part where injury occurred). If no appropriate diagnosis code is present, First Coast will deny the claim as not medically necessary.
We provided some examples below of ICD-10-CM codes identifying injuries that Medicare allows for tetanus vaccinations.

ICD-10-CM Code
Descriptor
S41.141A
Puncture wound with foreign body of right upper arm
S01.511A
Laceration without foreign body of lip
We also included below the Current Procedural Terminology (CPT®) codes for tetanus vaccinations:

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)
GY modifier for routine vaccinations
Note: For routine vaccination services, it is recommended to append the GY modifier. This modifier is defined via the Healthcare Common Procedure Coding System (HCPCS) as identifying an “Item or service statutorily excluded or Does not meet the definition of any Medicare benefit.” Lines with this modifier are thereby submitted as non-covered and will be denied.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.