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Last Modified: 7/17/2022 Location: FL, PR, USVI Business: Part A, Part B

Avoid claim processing delays when billing tetanus vaccinations

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 when they are directly related to the treatment of an injury or direct exposure to a disease or condition. 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 just a few examples below of ICD-10-CM codes identifying injuries that Medicare allows for tetanus vaccinations.

ICD-10-CM Code
Laceration without foreign body, left lower leg – initial encounter
Laceration without foreign body of lip – subsequent encounter
Puncture wound with foreign body of right upper arm – initial encounter
Open bite of left hand – initial encounter
Abrasion, left lower leg – subsequent encounter
We also included below the Current Procedural Terminology (CPT) codes for tetanus vaccinations:

CPT Code
Tetanus and diphtheria toxoids, older than 7
Tetanus, diphtheria toxoids and acellular pertussis vaccine, older than 7
Immunization administration
Immunization administration (ea. additional vaccine)
GY modifier for routine tetanus vaccinations
Routine tetanus vaccination services are not covered by Medicare. If you are billing for a routine tetanus vaccination, it is recommended to append the GY modifier. This modifier is defined via the Healthcare Common Procedure Coding System 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.