Pneumococcal Vaccine and Administration - JF Part B

Medicare covers both vaccine and administration under Part B:

• Both vaccine and administration costs covered by recognized providers
• Under incident to supervision, includes nurses, medical assistants, and pharmacists
• Physician order not required
• Assignment must be accepted on all vaccine claims
• Two types of pneumococcal vaccines:
• Conjugate: PCV13 (CPT 90670), PCV15 (CPT 90671), PCV20 (CPT 90677), PCV21 (CPT 90684)
• Polysaccharide: PPSV23 (CPT 90732)
• If sole purpose to administer vaccine, no separate E/M office visit allowed
• Influenza and pneumonia vaccines administered same day, may bill both administration HCPCS (G0008 and G0009, respectively)

To learn more about billing pneumococcal, visit the Influenza and Pneumonia Billing webpage.

HCPCS/CPT Codes

• 90684 - Pneumococcal Conjugate vaccine, 21 valent (PCV21)
• 90670 - Pneumococcal Conjugate vaccine, 13 valent (PCV13)
• 90671 - Pneumococcal Conjugate vaccine, 15 valent (PCV15)
• 90677 - Pneumococcal Conjugate vaccine, 20 valent (PCV20)
• 90732 - Pneumococcal polysaccharide vaccine, 23 valent (PPSV23)
• G0009 - Administration of pneumococcal vaccine
• M0201 - Additional administration of pneumococcal, influenza, hepatitis B, and/or COVID-19 vaccine inside patient’s home; reported only once per date of service

Frequency

• Revised February 3, 2025, recommendations found in CMS Advisory Committee on Immunization Practices (ACIP) CMS Change Request (CR) 13898
• “Revisions to Medicare Part B Coverage of Pneumococcal Vaccinations Policy”
• Initial vaccine to beneficiaries who never received vaccine under Medicare Part B
• Different, second vaccine recommended one year after first vaccine administered
• Adults aged 50 and older, who have not previously received pneumococcal conjugate vaccine (PCV), or whose previous vaccination history unknown:
• Should receive one dose of PCV (either PCV21, PCV20 or PCV15)
• When PCV15 administered, follow with PPSV23 dose
• Recommended one-year interval between administering PCV15 and PPSV23
• Minimal interval eight weeks for adults with immunocompromising condition, cochlear implant, or cerebrospinal fluid leak
• To decrease risk for invasive pneumococcal disease caused by serotypes unique to PPSV23
• Adults aged 50 and older who completed vaccine series (both PCV13 and PPSV23):
• PCV21 or PCV20 dose recommended at least 5 years after last pneumococcal vaccine
• Adults aged 50 and older and adults aged 19-49 years with certain underlying medical conditions or other risk factors who have received PCV13 only:
• Recommended dose PCV21 or PCV20 (at least one year after PCV13 dose or PPSV23) to complete pneumococcal vaccine series

Diagnosis Code

Z23 - Encounter for immunization

Coverage

All Medicare beneficiaries are eligible

Payment

• Coinsurance and deductible waived
• G0009 and M0201
• 2025 Vaccine Administration Rates (Influenza, Pneumococcal, Hepatitis B and COVID-19)
• 906xx and 90732 under CMS Vaccine Pricing-Medicare Part B Drug Average Sales Price (ASP)

Noridian Medicare Portal

• Yes; however, only HCPCS 90670 and 90732 (Pneumococcal Vaccines) display
• Up to 10 previous dates of service for rendering NPI
• Viewable if beneficiary has Medicare Part B coverage
• Use Noridian Medicare Portal (NMP) to check eligibility

Roster Billing

• Allows mass immunizers simplified, same date, CMS-1500 submission with beneficiary roster forms

Resources

• Influenza and Pneumonia Billing
• CDC Pneumococcal Vaccine Timing for Adults
• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.4.2
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 10
• CMS Medicare Learning Network (MLN) Publications
• CMS Medicare Preventive Services
• CMS Roster Billing for Mass Immunizers
• CMS Vaccine Pricing