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Coverage and reporting requirements for pneumococcal vaccine in Medicare beneficiaries has recently changed. Here's what you need to know.
Coverage and reporting requirements for pneumococcal vaccine in Medicare beneficiaries has recently changed. Under the most recent guidelines as described in the Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), Section 126.96.36.199 (Immunizations), Medicare will cover:
• An initial pneumococcal vaccine to all Medicare beneficiaries who have never received the vaccine under Medicare Part B; and
• A different, second pneumococcal vaccine one year after the first vaccine was administered.
Medicare defines "one year" to mean that 11 full months have passed following the month in which the previous pneumococcal vaccine was administered.
Note also that per the "Medicare Claims Processing Manual," Chapter 18 (Preventive and Screening Services), Section 10.1.1 (Pneumococcal Vaccine), a Medicare beneficiary may receive influenza vaccination upon request, without a physician's order and without physician supervision.
There are currently two vaccines for pneumococcal immunization in adults: the 23-valent pneumococcal polysaccharide vaccine (PPSV23) and the 13-valent pneumococcal conjugate vaccine (PCV13). The vaccines may be recognized by their brand names, Pneumovax 23 (Merck & Co.) and Prevnar 13 (Wyeth Pharmaceuticals, a subsidiary of Pfizer). PPSV23 has been used in adults over the age of 65 for many years, while PCV13 has been approved for adults age 50 and older since December 30, 2011.
Because Medicare coverage is specific to vaccine type and sequence of vaccination - and because "Receiving multiple vaccinations of the same vaccine type is not generally recommended," according to the Centers for Medicare & Medicaid Services (CMS) - you must consider the patient's prior pneumococcal vaccination history. CMS publication MLN Matters® Number: MM9051, explains:
For example, if a beneficiary who is 65 years or older received the 23-valent pneumococcal polysaccharide vaccine (PPSV23) a year or more ago, then the 13-valent pneumococcal conjugate vaccine (PCV13) should be administered next as the second in the series of the two recommended pneumococcal vaccinations.
Although providers ideally should have access to a patient's vaccination history (e.g., via electronic health records), to ensure the proper vaccinations are given, the Medicare Benefit Policy Manual, Chapter 15, Section 188.8.131.52 specifies:
Those administering the vaccine should not require the patient to present an immunization record prior to administering the pneumococcal vaccine, nor should they feel compelled to review the patient's complete medical record if it is not available. Instead, provided that the patient is competent, it is acceptable to rely on the patient's verbal history to determine prior vaccination status.
If the provider wants to be sure that he or she is financially protected, the provider may ask the Medicare patient to sign an Advance Beneficiary Notice of Noncoverage (ABN), prior to administering the vaccine. This allows the provider to recoup the cost of the vaccine by balance-billing the patient, if Medicare denies the claim (for instance, due to coverage frequency limits). When filing your claim, apply modifier GA Waiver of liability statement on file when the provider believes the service is not covered and the office has a signed ABN on file.
You can download the current version of the ABN and instructions from the CMS website. ABNs must be reproduced on a single page (either letter or legal-size). To be safe, you should reproduce the ABN "as is" from the CMS website.
Another form that always should be given to the patient is the Vaccine Information Sheets (VIS). There is a different VIS for each of the two pneumonia vaccines. Like an ABN, the VIS must be presented to the patient prior to receiving the vaccine, so that the patient and/or their guardian can make an informed decision to receive the vaccine.
When reporting services to Medicare, the vaccine and administration codes are:
HCPCS Administration Code
CPT® code for Vaccine
G0009 Administration of pneumococcal vaccine
90670 Pneumococcal 13 valent, for intramuscular use
PPSV23 (Pneumovax 23)
90732 Pneumococcal polysaccharide vaccine, 23-valent, adult, or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
The ICD-9-CM diagnosis codes pneumonia vaccine prophylaxis is V03.82 Pneumococcal prophylaxis. In ICD-10 (scheduled for implementation Oct. 1, 2015), all immunization encounters will have Z23 Encounter for immunization as the primary diagnosis; procedure codes will identify the type(s) of immunizations given.
*For complete information about reporting influenza vaccines and administration, see CMS publication MLN Matters® Number: SE1431, "2014-2015 Influenza (Flu) Resources for Health Care Professionals"