Pneumococcal Vaccine and Administration - JE Part A

Medicare covers pneumonia (pneumococcal, PPV), under Part B:

• Both vaccine and administration costs covered by recognized providers
  • Includes nurses, pharmacists, under incident to supervision
• No beneficiary coinsurance or unmet deductible applied
• Assignment must be accepted on all vaccine claims and physician order not required
• 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 E/M office visit allowed
• Influenza and pneumonia vaccines administered same day, may bill both administration

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

HCPCS/CPT Codes

• 90684 - Pneumococcal Conjugate vaccine, 21 valent (PCV21) new 2024
• 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

Frequency

• Initial vaccine to beneficiaries who never received vaccine under Medicare Part B
• Different, second vaccine one year after first vaccine was administered
• Adults aged 50 and older who have not previously received pneumococcal conjugate vaccine (PCV) or whose previous vaccination history is unknown
  • Should receive 1 dose of PCV (either PCV21, PCV20 or PCV15)
  • When PCV15 used, should be followed by dose of PPSV23
• Adults aged 50 and older who completed vaccine series (both PCV13 and PPSV23) and received at aged 50 and older
  • If decision to administer PCV21 or PCV20 made, 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 of PCV21 or PCV20 (at least 1 year after PCV13 dose or PPSV23) to complete pneumococcal vaccine series

Diagnosis Code

Z23 - Encounter for immunization

Coverage

All Medicare beneficiaries are eligible

Payment

• Copayment/coinsurance waived; Deductible waived
• G0009 payment based on Locality-Adjusted Payment Rates
• 906xx payment found CMS Vaccine Pricing-Medicare Part B Drug Average Sales Price (ASP)

Noridian Medicare Portal

Yes. HCPCS codes 90670 and 90732 (Pneumococcal Vaccines) will display up to 10 previous dates of service and with the rendering NPI. These codes will only be viewable if the beneficiary has Medicare Part B coverage.

Roster Billing

• Simplifies claims by allowing mass immunizers to submit one claim form with a list of several immunized beneficiaries on the same date
• Use Medicare Beneficiary Identifiers (MBIs) to check eligibility and submit claims

Resources

• 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