Pneumococcal disease is an infection caused by the bacteria Streptococcus pneumoniae, also known as pneumococcus. The most common types of infections caused by this bacterium include middle ear infections, pneumonia, blood stream infections (bacteremia), sinus infections, and meningitis. Invasive pneumococcal infection kills thousands of people in the United States each year, most of them 65 years of age or older. While influenza viruses generally strike during the winter months, pneumococcal disease occurs year round. The pneumococcal vaccine is very good at protecting adults against invasive pneumococcal disease and preventing severe illness, hospitalization, and death. Medicare provides coverage of the pneumococcal vaccine and its administration for all Medicare beneficiaries regardless of risk for the disease.
Coverage Information
Coverage of pneumococcal polysaccharide vaccine (PPV) and its administration was added to the Medicare Program on July 1, 1981. Coverage of pneumococcal conjugate vaccine and its administration was added to the Medicare Program on January 1, 2008.
Medicare provides coverage of pneumococcal vaccination once in a lifetime generally for all Medicare beneficiaries. (The beneficiary should not have received the pneumococcal vaccine within the last five years.) Medicare may provide coverage of additional vaccinations based on risk or uncertainty of beneficiary pneumococcal status.
Coding and Diagnosis Information
Medicare providers must use the following Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) codes listed
90669 – Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use
90732 – Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
G0009 – Administration of pneumococcal vaccine
Diagnosis Requirements
When a Medicare provider files a claim, they must report the appropriate diagnosis code. If the sole purpose of the visit was to receive the pneumococcal vaccine, or if the pneumococcal vaccine is the only service billed on a claim, the provider must report diagnosis code V03.82.
However, if the purpose of the visit was to receive both the pneumococcal and influenza virus vaccine, providers must report diagnosis code V06.6.
V03.82 – Need for prophylactic vaccination and inoculation against bacterial diseases; other specified vaccinations against single bacterial diseases; Streptococcus pneumoniae (pneumococcus)
V06.6 -Need for prophylactic vaccination and inoculation against combinations of diseases; Streptococcus pneumoniae (pneumococcus) and influenza
Reasons for Claim Denial
Medicare providers may find specific payment decision information on the remittance advice (RA). The RA will include Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) that provide additional information on payment adjustments.
Billing and Coding Guidelines
Frequency of Administration CPT CODE 90732
Once in a lifetime/
Medicare may cover
additional vaccinations
based on risk
An initial pneumococcal vaccine to Medicare beneficiaries who have never received the vaccine under Medicare Part B; and A different, second pneumococcal vaccine 1 year after the first vaccine was administered
Diagnosis Code: Z23
• For state-supplied vaccine, bill the CPT code.
• For non-state-supplied vaccine, bill the CPT code and append the -22 modifier.
Pneumococcal vaccine:
• FCHP requires that CPT code 90669, 90670, or 90732 be billed for the pneumococcal vaccine and HCPCS code G0009 for the administration.
• If administered on the same day as a physician service is performed, use CPT code 90460, 90461, or 90471-90474 to report the administration of the vaccine.
• FCHP does not require an invoice be submitted for the pneumococcal vaccine.
When a significant, separately identifiable E&M service is performed in addition to administration of a vaccine or toxoid, a claim for the E&M service may be reported with the appropriate E&M CPT code, appended by the modifier -25.
Pneumococcal Vaccine – change in policy does not
include the reimbursement for the
pneumococcal vaccine. Members
are directed to their primary care
physician for recommendation and
administration of this vaccine.
Pneumococcal vaccinations should
be filed with CPT 90732 for
the Pneumovax vaccine and HCPCS
G0009 for the administration
of Pneumovax.
include the reimbursement for the
pneumococcal vaccine. Members
are directed to their primary care
physician for recommendation and
administration of this vaccine.
Pneumococcal vaccinations should
be filed with CPT 90732 for
the Pneumovax vaccine and HCPCS
G0009 for the administration
of Pneumovax.
Pneumococcal Vaccine Codes 90669, 90670, 90732
• For state-supplied vaccine, bill the CPT code.
• For non-state-supplied vaccine, bill the CPT code and append the -22 modifier
CPT 90660 and Further Instruction Regarding the Pneumococcal Vaccine CPT 90669
BR 5744.6 provided the allowable payment rate for pediatric pneumococcal vaccine CPT code 90669;
however the coverage for CPT 90669 will not be effective until January 1, 2008. This CR instructs contractors to accept CPT 90669 for the reporting of pneumococcal vaccine. Carriers and A/B MACs shall submit the payment indicator of “1” and the deductible indicator of “1” in the record sent to CWF for CPT code 90669. This modifies BR 5744.6 to be effective for claims with dates of service on or after January 1, 2008.
CPT 90660 (FluMist, a nasal influenza vaccine) may be covered if the local claims processing contractor determines its use is medically reasonable and necessary for the beneficiary. The FDA approved FluMist for the 2007-2008 influenza season on September 19, 2007. Therefore, when payment is based on 95 percent of the AWP, the Medicare Part B payment allowance for CPT 90660 is $22.031, for claims with dates of service on or after September 19, 2007. This supersedes BR 5744.8.
B. Policy: The Medicare Part B payment allowance limits for influenza and pneoumococcal vaccines are 95 percent of the AWP as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department. Where the vaccine is furnished in the hospital outpatient department, payment for the vaccine is based on reasonable cost.
Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine
Effective for claims with dates of service on or after January 1, 2008, contractors shall submit the payment indicator of “1” and the deductible indicator of “1” in the record sent to CWF for CPT code 90669.
Effective for claims with dates of service on or after January 1, 2008, contractors shall accept claims containing CPT code 90669 when billing for Pneumococcal vaccine.
Effective for claims with dates of service on or after January 1, 2008, contractors shall not apply deductible and coinsurance to Pneumococcal vaccine, CPT code 90669 and its administration.
Effective for claims with dates of service on or after January 1, 2008, contractors shall instruct providers to bill HCPCS code G0009 when billing for the administration of CPT code 90669.
Data Collection and Analysis
We obtained all Medicare Part B claims from the National Claims History File for the period 2007–2011 for HCPCS codes 90669, 90670, 90732, and G0009. We then limited our review to claims with:
• a Medicare Status Code of 10—indicates that age was the qualifier for Medicare eligibility, and
• a diagnosis code of V03.82 or V06.6—(i.e., diagnosis codes indicating vaccination against Streptococcus pneumoniae).
We limited the period of review to 5 years (i.e., the period for which even immunocompromised beneficiaries should not be revaccinated) and allowed for one vaccination per type—90669 (PCV7), 90670 (PCV13), and 90732 (PPSV23)—per beneficiary. Our calculations as to whether a given vaccination constituted a second (or greater) vaccination of the same type were based on the order of occurrence for each vaccination. Finally, all claims reviewed were for beneficiaries aged 65 years or older
For HCPCS code 90669 (PCV7), 32 beneficiaries received 33 repeat vaccinations. (One beneficiary received three vaccinations, while all others received two.). Only two beneficiaries received repeat vaccinations from different providers. Each of the remaining 30 beneficiaries received repeat vaccinations from the same provider. Twenty-six beneficiaries received repeat vaccinations from the same North Palm Beach, Florida provider. That same provider also provided one of two vaccinations for the two beneficiaries receiving vaccinations from multiple providers
