Preventive Services Guide

Pneumococcal Vaccine and Administration

Pneumonia affects approximately 450 million people globally (seven percent of the population) and results in about four million deaths per year. Pneumonia was regarded by William Osler in the 19th century as “the captain of the men of death.” With the introduction of antibiotics and vaccines in the 20th century, survival improved. Nevertheless, in developing countries, and among the very old, the very young and the chronically ill, pneumonia remains a leading cause of death.

Coverage Criteria

All Medicare beneficiaries who never received the vaccine are covered for an initial vaccine
- Visit CDCs Pneumococcal Vaccine Timing for Adults
Physician order/presence not required by Medicare for coverage

Billing Tips

Submit single claims electronically unless provider is approved under ASCA exception waiver
- ASCA exceptions include:
  - Small providers, certain mass immunizers, providers who submit fewer than ten claims per month on an average during a calendar year
Roster claims may be submitted electronically or on paper

Roster Billing

Streamlined process for submitting vaccination claims for large groups of individuals
- All patients have the same service
- Not used for single patient billing
Patient roster form includes the following with a single modified CMS-1500 claim form as roster cover document for each facility where the services are rendered:
- Patients name, address, Medicare number, date of birth and gender
- Date of service
- Beneficiary signature or stamped "Signature on File"
- Providers name and identification number
- Control number for contractor
Immunization Roster Billing

Mass Immunizers

Must be properly licensed in the state in which they plan to operate flu clinics
Enrollment is ongoing and completed through the local A/B MAC
- Participation is limited to one year, must be renewed annually via the CMS Central Office by June 1^st
Must use roster billing process and bill to local MAC
Offer vaccines to a large number of individuals
Must accept assignment on vaccine and administration

HCPCS/CPT Coding

90670: Pneumococcal conjugate vaccine, 13 valent, for intramuscular use
90671: Pneumococcal conjugate vaccine, 15 valent, for intramuscular use
90677: Pneumococcal conjugate vaccine, 20 valent, for intramuscular use
90684: Pneumococcal conjugate vaccine, 21 valent, for intramuscular use. Effective 6/27/2024 with implementation date of 11/25/2024.
90732: Pneumococcal polysaccharide vaccine, 23 valent, adult or immunosuppressed patient dosage, when administered to individuals two years or older, for subcutaneous or intramuscular use.
G0009: PPV administration

ICD-10 Diagnosis Coding

Z23: Encounter for immunization

Additional ICD-10 codes may apply. See the CMS ICD-10 webpage for individual CRs and the specific ICD-10-CM codes Medicare covers for this service, and contact your MAC for guidance.

Cost Sharing

Copayment/coinsurance waived
Deductible waived

Reimbursement

Vaccine reimbursed at the nationally-established rate
MPFS: Fee Schedule Lookup

Nonparticipating Providers

Nonparticipating providers can choose not to accept assignment of administration
- Must submit an unassigned claim on beneficiary’s behalf
- May collect his/her usual charge for administration but cannot collect any fee upfront for vaccine