90472
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.15
Facility
$16.03
Non-Facility
$16.03
Documentation Required
- Documentation of medical indication consistent with ACIP recommendations or policy-specified indications (e.g., routine preventive immunization according to ACIP schedule, pregnancy, catch-up series, wound management).
- Immunization history and dates of prior tetanus-, diphtheria-, and pertussis-containing vaccine doses to determine eligibility, intervals (for example, >5 years for wound management vaccine indication, or timing for catch-up schedules and decennial boosters).
- For vaccine formulations with manufacturer- or previous-dose–dependent indications (e.g., Kinrix, Quadracel), documentation of prior vaccine brands and doses (e.g., Infanrix, Pediarix, Pentacel, Daptacel) as specified in the policy.
- Pregnancy status and gestational age for Tdap in pregnant women (policy: Tdap should be administered at 27–36 weeks’ gestation; coverage noted 'regardless of prior vaccination history' for pregnant women).
Key Coverage Criteria
- Tenivac (Td) indicated for prevention of tetanus and diphtheria in persons 7 years of age and older (booster every 10 years or as part of 3-shot series if unvaccinated).
- Diphtheria, tetanus toxoid, and whole-cell or acellular pertussis vaccines as preventive services according to the recommendations of the Advisory Committee on Immunization Practices (ACIP).
- Boostrix (GlaxoSmithKline), a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) as a preventive service for active booster immunization against tetanus, diphtheria, and pertussis as a single dose in individuals 10 years of age and older.
- CPT/HCPCS codes for administration (e.g., 90471, +90472) and vaccine product codes (e.g., 90700, 90715, 90696, 90697, 90698, 90696, 90697, 90698, 90723, 90702, 90714) when selection criteria/indications are met (see code table).
- ICD-10: Z23 (Encounter for immunization) listed as a covered diagnosis when selection criteria are met.
- ICD-10 codes for contaminated wounds / relevant injuries are listed as covered when indicating the need for tetanus-containing immunization (examples/list as provided in the policy): S00.00x+ - S00.97x+; S10.0xx+ - S10.97x+; S20.00x+ - S20.91x+; S30.0xx+ - S30.98x+; S40.011+ - S40.929+; S50.00x+ - S50.919+; S60.00x+ - S60.949+; S70.00x+ - S70.929+; S80.00x+ - S80.929+; S90.00x+ - S90.936+; S01.00x+ - S01.95x+; S11.011+ - S11.95x+; S21.001+ - S21.95x+; S31.000+ - S31.839+; S41.001+ - S41.159+; S5 [...]
1 Active Policy
AETNA-CPB-0653 — Diphtheria, Tetanus, and Pertussis Vaccines
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.