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Vaccination and inoculation coverage.
Medicare Part B vs. Part D Crossover Drugs
Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.
In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.
The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.
Vaccinations, or inoculations, are excluded under the Medicare medical benefit (Part B) unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as the following:
Tetanus antitoxin or booster vaccine
In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against diseases (e.g., smallpox, polio, diphtheria) is not covered under the medical benefit (Part B). However, Pneumococcal, Hepatitis B, and Influenza virus vaccines are exceptions to this rule.
The following vaccines are always covered under Part B and are never covered under the
Medicare pharmacy benefit (Part D):
The Pneumococcal vaccine is covered under Part B regardless of whether the vaccine is administered without a physician’s order and without physician supervision.
A second pneumococcal vaccine may be administered a year after the first vaccine was administered.
The Influenza vaccine is covered under Part B regardless of whether
the vaccine is ordered by a doctor of medicine or osteopathy.
The following vaccines are only covered under the Part B when reported with the appropriate diagnosis codes listed in the attachments
of this policy. In all other instances, the vaccines will not be covered under Part B and will only be covered under Part D.
The Hepatitis B vaccine is covered under Part B when given to an individual who is at high or intermediate risk of contracting Hepatitis B. (See Attachment D for the definition of high or intermediate risk and all the applicable diagnoses that meet this definition.)
The tetanus vaccine is covered under Part B when given to treat an acute injury sustained by an individual who is incompletely immunized.
To report the tetanus vaccine (90714) administration for the treatment of an injury or direct exposure to a disease or condition, append modifier AT (acute treatment) to the code for the vaccine to be covered under Part B, medical benefit. Claims submitted without modifier AT will be denied under Part B and will only be covered under the Medicare pharmacy benefit (Part D) for Medicare Advantage members who purchased this coverage.
The rabies vaccine is covered under Part B when given to an individual who is at high risk for rabies following an encounter with an animal. All other indications will be denied under Part B and will only be covered under the Medicare pharmacy benefit (Part D) for Medicare Advantage members who purchased this coverage.
The following vaccines are never covered under Part B and are only covered under Part D:
*At the time of this policy being published, there is no US Food and Drug Administration (FDA) approval for these vaccines; therefore, these vaccines are considered experimental/investigational, and are not covered under any benefit.
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