- Preventive Services Guide
- Medicare Preventive Services Resource Guide
- Alcohol Misuse and Counseling
- Annual Wellness Visit Screening
- Bone Mass Measurements
- Cardiovascular Disease Screening Tests
- Colorectal Cancer Screening
- Counseling to Prevent Tobacco Use
- Depression Screening
- Diabetes Screening
- Diabetes Self-Management Training
- Glaucoma Screening
- Hepatitis B Virus Screening
- Hepatitis B Virus Vaccine and Administration
- Hepatitis C Virus Screening
- Human Immunodeficiency Virus Screening
- Influenza Virus Vaccine and Administration
- Initial Preventive Physical Examination
- Intensive Behavioral Therapy for Cardiovascular Disease
- Intensive Behavioral Therapy for Obesity
- Lung Cancer Screening Counseling and Annual Screening for Lung Cancer with Low-Dose Computed Tomography
- Medical Nutrition Therapy
- Pneumococcal Vaccine and Administration
- Prolonged Preventive Services
- Prostate Cancer Screening
- Screening for Cervical Cancer with Human Papillomavirus Tests
- Screening for Sexually Transmitted Infections and HIBC to Prevent STIs
- Screening Mammography
- Screening Pap Tests
- Screening Pelvic Examinations
- Ultrasound Screening for Abdominal Aortic Aneurysm
- Vaccinations
- Related Articles
- Medicare Preventive Services Resource Guide
- The Annual Wellness Visit
- Medicare’s Annual Wellness Visit in Illinois: Understanding the Benefit and Preventing Denials
- Medicare’s Annual Wellness Visit in Minnesota: Understanding the Benefit and Preventing Denials
- Medicare’s Annual Wellness Visit in Wisconsin: Understanding the Benefit and Preventing Denials
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
- 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
- ASCA exceptions include:
- 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 1st
- 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
- 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
Related Content
- CMS IOM Publication 100-04, Medicare Claims Processing Manual,
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.4.2
- MLN® Educational Tool: Medicare Preventive Services
- MLN Matters® MM12439 Revised: Claims Processing Instructions for the New Pneumococcal 15-valent Conjugate Vaccine Code 90671 and Pneumococcal 20-valent Conjugate Vaccine Code 90677
- Pneumococcal Vaccine Timing for Adults
Reviewed 10/12/2023