Abstract
Tetanus is a neurologic syndrome caused by a neurotoxin elaborated at the site of injury by Clostridium tetani. Nearly all cases of tetanus occur in nonimmunized or inadequately immunized individuals. Available evidence indicates that complete primary vaccination with tetanus toxoid provides long-lasting protection; 10 years for most recipients. To maintain adequate protection a booster dose every 10 years is recommended. Consequently, after complete primary tetanus vaccination, boosters, even for wound management, need to be given only every 10 years when wounds are minor and uncontaminated. For other wounds, a booster is appropriate if the patient has not received tetanus toxoid within the preceding five years. (MMWR 40: No. RR-10, 1991) Immunizations are generally excluded from coverage under Medicare unless they are directly related to the treatment of an injury or direct exposure to a disease or condition. In the absence of injury or direct exposure, preventive immunization is not covered. This medical policy coverage article documents CGS coverage and coding guidelines for the administration of tetanus toxoids.
Indications:
One booster injection of tetanus toxoids is covered in a patient who has had primary immunization, has sustained a high-risk wound (a wound which affords anaerobic conditions or which has been incurred in a circumstance with probability of exposure to tetanus spores), and has not received the booster within the last 5 years.(MMWR Aug 8, 1991/40(RR10:1-28)
These injections are also covered when given for an acute injury (clean, minor injury or high-risk wound) when a patient has not received primary immunization or the primary immunization status is not known, and the patient has sustained a high-risk wound. Patients with unknown or uncertain previous immunization histories should be considered to have no previous tetanus toxoid doses. For inadequately vaccinated patients of all ages, completion of primary vaccination at the time of discharge or at follow-up visits should be ensured. (MMWR 40: No. RR-10, 1991)
Limitations:
When a tetanus booster is given to a patient in the absence of an injury/potential exposure, the injection does not meet the coverage criteria for Medicare (even though it may be appropriate preventative treatment). Preventative services should not be billed to Medicare.
If a medication is determined not to be reasonable and necessary for diagnosis or treatment of an illness or injury, the entire charge will be excluded (i.e., for both the drug and its administration). Also excluded from payment is any charge for other services (such as office visits) which are primarily for the purpose of administering a noncovered injection (i.e., an injection that is not reasonable and necessary for the diagnosis or treatment of an illness or injury).
Coding Guidelines:
General Guidelines for claims submitted to Part A or Part B MAC:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient’s condition for which the service was performed.
Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines (for outpatient services):
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, revised 09/05/2008, for complete instructions.
Services not meeting medical necessity guidelines should be billed with modifier -GA or -GZ as appropriate.
The –GA modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.
The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary.
If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier.
For claims submitted to the Part B MAC:
All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same day.
Claims for CPT codes 90702, 90714, J1670 are payable under Medicare Part B in the following places of service: office (11), urgent care facility (20) , nursing facility (32), and independent clinic (49).
For claims submitted to the Part A MAC:
Hospital Inpatient Claims:
- The hospital should report the patient’s principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
- The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
- For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)
Hospital Outpatient Claims:
- The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).
- The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.