Knowledge Base Article

Q:

Does Medicare Part B cover tetanus vaccinations?

A:

Yes, but not as a preventive service. 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. Claims including tetanus vaccinations must include the proper procedure and diagnosis codes to support the medical necessity for the vaccination. According to a recent article by First Coast, the Medicare Administrative Contractor (MAC) for Jurisdiction N, “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.” The article goes on to list a few examples of ICD-10-CM codes identifying injuries that Medicare allows for tetanus vaccinations.

The First Coast article also explains that 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.”

Medicare does cover some routine vaccinations:

• Influenza Virus Vaccine is covered once a flu season. A physician’s order is not required for a patient to obtain a flu shot.
• Pneumococcal Pneumonia Vaccine – CDC recommends pneumococcal vaccination (PCV13 or Prevnar13®, and PPSV23 or Pneumovax23®) for all adults 65 years or older:
• Give a dose of PCV13 to adults 65 years or older who have not previously received a dose. Then administer a dose of PPSV23 at least 1 year later.
• If the patient already received one or more doses of PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose of PPSV23.
• Medicare covers both of these vaccines and a physician’s order is not required.
• Hepatitis B Vaccine – Medicare provides coverage under Part B for hepatitis B vaccine and its administration, furnished to a Medicare beneficiary who is at high or intermediate risk of contracting hepatitis B.

Refer to Section 50.4.4.2 – Immunizations of Chapter 15 of the Medicare Benefit Policy Manual for more information on routine immunizations.