Tuesday, September 26, 2023

Does Medicare Pay For Pneumococcal Vaccine

What Is Prevnar 13

Medicare & You: Vaccines

Prevnar 13 is a vaccine that protects against pneumococcal disease.

Streptococcus pneumonia is a bacterium that can cause various infections, ranging from mild ear and sinus infections to dangerous pneumonia and bloodstream infections.

Many strains of these bacteria exist, and Prevnar 13 protects against 13 of the most common. The Pneumovax 23 vaccine protects against 12 of the same strains as Prevnar 13, plus 11 additional ones.

CDC data show that Prevnar 13 is effective in protecting people aged 65 years and over against pneumococcal disease.

Initially, in 2014, the CDC Advisory Committee on Immunization Practices recommended routine Prevnar 13 vaccination ahead of Pneumovax 23 vaccination a year later for those aged 65 years and over.

In 2019, the ACIP changed the recommendation to a single dose of Pneumovax 23 because the routine vaccination of children has caused a decline in the bacterial strains that commonly cause disease.

However, the ACIP recognized that some older people should still receive Prevnar 13, including those who:

  • live in a nursing home or another long-term care facility
  • have cochlear implants
  • are immunocompromised and have never received a pneumonia vaccine
  • have a cerebrospinal fluid leak
  • visit areas where doctors do not routinely vaccinate children with Prevnar 13

Who Should Get The Pneumonia Shot

The U.S. Centers for Disease Control and Prevention recommends that everyone over the age of 65 which includes most Medicare beneficiaries should get the Pneumovax 23 vaccine.

Who Should Get the Pneumovax 23 Shot?

  • All people age 65 or older
  • Cigarette smokers between the ages of 19 through 64
  • People between 2 and 64 years old with certain medical conditions

The Prevnar 13 vaccine is generally recommended for children younger than 2 years old or for older people with certain medical conditions.

The CDC suggests anyone 65 and older can ask for the Prevnar 13 vaccine if they decide with their doctor that it would be beneficial to them.

What Are The Costs

Medicare Part B covers 100% of the costs for Prevnar 13. Individuals do not pay a copayment or coinsurance, as long as they use a Medicare-approved provider.

The Part B deductible does not apply to the Prevnar 13 and Pneumovax 23 vaccinations. Therefore, the beneficiary should not receive a bill or have to pay any costs upfront.

The only cost is the Part B monthly premium. In 2021, the standard premium is $148.50.

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Prevnar 13 And Pneumovax 23

There are two pneumonia vaccines available: Prevnar 13 and Pneumovax 23. Each shot protects against different strains of bacteria that can cause pneumonia and related complications like meningitis.

The Prevnar 13 vaccine protects against 13 Streptococcus pneumoniae strains. Doctors may recommend the Prevnar 13 shot for:

  • Some older adults
  • People with underlying immune conditions
  • Those who live in long-term care facilities

Although Prevnar 13 isn’t necessary for everyone, Medicare does cover the pneumonia shot. Beneficiaries should talk to their doctor about whether to get one or both vaccines.

Where Can I Get Vaccines I Need

Pneumonia shots: Coverage, costs, and eligibility

You can get most vaccines at a pharmacy, doctors office, clinic or community health center. Talk with your doctor about what vaccines you may need. Your doctor or Part D plan provider can also help you understand whether your cost will be affected by where you go to get the vaccines that your doctor recommends.

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Vaccines Covered By Medicare Part D

Medicare Part D covers all commercially available vaccines needed to prevent illness. You can get Part D coverage through a stand-alone Medicare prescription drug plan or a Medicare Advantage plan that includes drug coverage.

Vaccines covered by Part D include the following:

  • Shingles vaccine: One-time vaccine given in two shots over two to six months
  • Tdap vaccine : One shot if youve never been vaccinated, and a booster every ten years
  • Other vaccines covered: Vaccines that are “reasonable and necessary” to prevent illness and are not covered by Part B

Part D may also cover vaccines you may need if you are traveling internationally. Talk with your doctor about your travel plans and ask what vaccines are recommended.

Do I Have To Pay For Vaccines With Medicare

You pay nothing for vaccines covered by Part B flu, pneumonia and Hepatitis B as long as your provider accepts Medicare.

Your cost for vaccines covered by Part D will depend on your specific plan. You may pay a copay or coinsurance, but it will depend on your plan and the provider.

The location where you get vaccinated may also affect your cost. For example, your costs may be lower if you get a vaccine at a pharmacy versus in a doctors office.

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Vaccines Covered By Medicare Part B

Medicare Part B covers three important vaccines as part of its preventive care benefits.

Covered vaccines include the following:

  • Flu vaccine: Annual vaccine given in one shot before or during flu season, usually November through April
  • Pneumonia vaccine: One-time vaccine given in two shots at least one year apart
  • Hepatitis B vaccine: One-time vaccine given in two to four shots over one to six months for people who are medium to high risk, including people with diabetes

Part B also covers vaccines you may need if youre exposed to a harmful virus or bacteria by accident. You might need a tetanus shot, for example, if you step on a rusty nail. Or you may need rabies shots if youre bitten by a stray dog.

Will Medicare Pay For Both Pneumonia Shots

Medicare Vaccinations for Medical Coders

Yes, Medicare pays for the two types of pneumococcal vaccines approved for use in the United States.

The vaccines offer protection from severe pneumococcal infections caused by common strains of the bacteria Streptococcus pneumoniae. But you should know pneumonia may be caused by bacteria, viruses, or fungi.

Pneumococcal vaccines dont protect against every strain of bacteria that cause pneumococcal infections. There are over 90 types of pneumococcal strains.

  • The Pneumococcal conjugate vaccine protects you from 13 different types of pneumococcal bacteria. It is an injection given into a muscle by a healthcare professional.
  • The Pneumococcal polysaccharide vaccine offers protection against 23 different varieties of pneumococcal bacteria. The 11 extra strains covered by PPSV23 vaccine are responsible for around 32% to 37% of invasive pneumococcal disease in older adults. It is an injection given either under the skin or into a muscle by a healthcare professional.

Some people may benefit from both vaccines. If you and your doctor decide two pneumococcal vaccines are necessary, Centers for Disease Control and Prevention recommends you should get the PCV 13 vaccine first whenever possible. But if you already received a PPSV 23 shot, your PCV 13 shot should be given at least one year later.

Let your healthcare provider know if youre allergic to any part of the pneumococcal vaccines or ever had an allergic reaction to a vaccine.

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Does Medicare Cover Pneumonia Shots

  • Medicare covers two pneumonia shots, including Prevnar 13. This article discusses how enrollees can get the total cost of this vaccine covered by Medicare.

Medicare beneficiaries seeking to maintain their health through safe and effective vaccines may wonder which vaccines are covered by their plan. Medicare Part B does cover two pneumonia vaccinations, including Prevnar 13, as routine preventative care. Coverage for pneumonia vaccines is also available through Medicare Part C plans.

Medicare And Pneumonia Vaccinations

There are certain persons who should consider getting vaccinated against pneumococcal infections, as following: babies, people aged over 65 years old, anyone at risk to develop the disease and people suffering from illnesses that make them liable to get infected.

In case you are over 65 years old, this means that you can take advantage of your Medicare insurance plan. But does this cover the costs of the shot or not?

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Prevnar 13 Is Covered By The Medicare Part B Fee

Medicare covers administration of 2 different pneumococcal vaccines for adults aged 65 and older.2 Prevnar 13® is covered for the following patient types:

Adults aged 65 and older who are pneumococcal vaccine naive

Adults aged 65 and older who were previously vaccinated with Pneumovax® 23 at least 1 year prior

Provided that the patient is competent, it is acceptable to rely on the patientâs verbal history to determine prior vaccination status.2

User License Agreement And Consent To Monitoring

Why Does My Shingles Vaccine Cost So Much?

End User Agreements for Providers

Some of the Provider information contained on the Noridian Medicare web site is copyrighted by the American Medical Association, the American Dental Association, and/or the American Hospital Association. This includes items such as CPT codes, CDT codes, ICD-10 and other UB-04 codes.

Before you can enter the Noridian Medicare site, please read and accept an agreement to abide by the copyright rules regarding the information you find within this site. If you choose not to accept the agreement, you will return to the Noridian Medicare home page.





Consent to Monitoring

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Influenza And Pneumonia Billing

Medicare covers both the costs of the vaccine and its administration by recognized providers. There is no coinsurance or co-payment applied to this benefit and a beneficiary does not have to meet his or her deductible to receive it. Assignment must be accepted on all vaccine claims and a physician order is not required.

Influenza and pneumonia vaccinations and administration are covered under Part B, not Part D.

If a physician sees a beneficiary for the sole purpose of administering one of these vaccines, an office visit cannot be billed. However, if the beneficiary receives other services which constitute an office visit, then one can be billed.

If both vaccines are administered on the same day, providers are entitled to receive payment for both administration fees.

The diagnosis code used for these vaccines and administration is Z23 .

On this page, view the below information:

Is Vaccine Coverage Worse In The 12 States That Haven’t Expanded Their Medicaid Programs Than In Those That Have

Although it may seem that there could be less adult vaccine coverage in states that havent expanded Medicaid, that isnt the case. In fact, all of these states offer some vaccine coverage. Compared to the states that have expanded Medicaid, they dont fall behind due to the variation that still exists in those states.

For context, here are the 12 states that havent expanded Medicaid:

  • Alabama

  • Wisconsin

  • Wyoming

To give you a better idea of the variation among these non-expanded states, here are a few examples of the vaccine coverage they offer for adults:

  • Alabama Medicaid covers five of the recommended adult vaccines .

  • Mississippi Medicaid covers all 13 recommended vaccines.

  • Wyoming Medicaid provides flu shots for all adult members, but other vaccine coverage will depend on the plan you have.

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Are There Different Vaccines For Medicaid

No. Medicaid vaccines are the same as youd receive through any other program or form of insurance. And Medicaid-covered vaccines are always administered by qualified professionals such as pharmacists and healthcare workers. This also applies to COVID-19 vaccines. At the height of the pandemic, some mass vaccination sites also brought in active-duty troops from the National Guard to give shots, and they were also qualified to do so.

Prevention Of Acute Exacerbations Of Copd In Persons With Moderate Severe Or Very Severe Copd

Provider Compliance: Medicare Flu Shot Payment & Billing Overview

The American College of Chest Physicians and Canadian Thoracic Society guideline on “Prevention of acute exacerbations of COPD” states that in patients with COPD, the panel suggests administering the 23-valent pneumococcal vaccine as part of overall medical management but did not find sufficient evidence that pneumococcal vaccination prevents acute exacerbations of COPD .

Code Code Description

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How Effective Are Pneumococcal Vaccinations

While both vaccines work well, neither can prevent all cases. But they can reduce your risk of developing pneumonia.

For every 20 adults who receive a single shot of PPSV23, 10 to 17 will be protected against pneumonia, according to the CDC.

The CDC reports that the effectiveness of the PCV13 shot varies by age for a serious condition called invasive pneumococcal disease a group of pneumococcal bacteria that cause sepsis and meningitis among other conditions.

IPD infects an estimated 35,000 Americans every year and kills about 4,200, according to the CDC.

A Single PCV13 Shots Effectiveness by Age

Children 2 and Younger
Eight in 10 protected against invasive pneumococcal disease.
65 and Older
Three in every four protected against invasive pneumococcal disease.

PCV13 was also effective in protecting nine in every 20 adults 65 and older against pneumococcal pneumonia, according to the CDC.

Medicare Now Covers The 20

Medicare began covering the new 20-valent pneumococcal conjugate vaccine on Oct. 1.

The Centers for Medicare & Medicaid Services suggests submitting separate claims for this vaccine using CPT code 90677, Pneumococcal conjugate vaccine, 20 valent , for intramuscular use. Dont forget to also report the appropriate CPT code for administration of the vaccine.

Part B Medicare administrative contractors began processing these claims on Oct. 4, and will deny claims for shots given July 1Sept. 30 .

Kent Moore, Senior Strategist for Physician Payment

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Changes Made To The Vaccination Program For Children

Based on the types of pneumococcal bacteria currently circulating in Québec and which cause serious infections, an expert committee recommends using a mixed schedule for young children. Therefore, since September 1, 2020, the vaccination schedule for children has included two doses of Synflorix® and one dose of Prevnar 13®.

Experts consider that this schedule is just as effective as three doses of Synflorix® or three doses of Prevnar 13®. The three doses produce a very strong immune response to the 13 most common types of pneumococcus. In addition, by decreasing the number of doses of Prevnar 13®, this new schedule helps reduce local reactions caused by Prevnar 13® , which occur more frequently than with Synflorix®.

Québec is the only place where both vaccines are used to vaccinate children against pneumococcal infections. Québec had also the only place where, based on serious studies, two doses of human papillomavirus vaccine were given instead of three when HPV immunization was introduced in 2008. Now, most countries do the same as Québec.

To find out more about the vaccines used and the benefits of immunization, go to Pneumococcal Polysaccharide Vaccine and Pneumococcal Conjugate Vaccines.

Billing Considerations For Part B Vaccines

Is the Pneumonia Vaccine Covered by Medicare?

Whether participating or non-participating in Medicare, physicians must accept assignment of the Medicare vaccine payment rate and may not collect payment from the beneficiary for the vaccine.

Non-participating physicians may choose not to accept assignment on the administration fee. When a non-participating physician or supplier provides the services, the beneficiary is responsible for paying the difference between what the physician or supplier charges and the amount Medicare allows for the administration fee. The limiting charge provision does not apply to the influenza benefit.The influenza and pneumococcal vaccines and the administration of these vaccines are not subject to the Medicare Part B deductible or co-insurance. Medicare pays at 100% of the allowable amounts. However, the Hepatitis B vaccine and administration are subject to the deductible and co-insurance. Medicare pays at 80% after the patient has met their Part B deductible.Medicare will pay two administration fees if a beneficiary receives both the influenza virus and the pneumococcal vaccine on the same day.Claims for the hepatitis B vaccine must include the name and NPI of the ordering physician, as Medicare requires that the hepatitis B vaccine be administered under a physicians order with supervision. This is not necessary for the influenza and pneumococcal vaccines for which Medicare does not require a physician’s order or supervision.

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Pneumovax 23 Cpt Code

The CPT code for PNEUMOVAX 23 is 90732.

This CPT code is effective as of January 2017 as set forth in the Current Procedural Terminology 2017.

The information provided here is compiled from sources believed to be accurate, but Merck makes no representation that it is accurate. Consult the relevant manual and/or other guidelines for a description of each code to determine the appropriateness of a particular code and for information on additional codes. This information is subject to change. Merck cautions that payer coding requirements vary and can frequently change, so its important to regularly check with each payer as to payer-specific requirements.

You are solely responsible for determining the appropriate codes and for any action you take in billing. The information provided here is not intended to be definitive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor. Merck makes no warranties or guarantees, expressed or implied, concerning the accuracy or appropriateness of this information for your particular use given the frequent changes in public and private payer billing. The use of this information does not guarantee payment or that any payment received will cover your costs. Diagnosis codes should be selected only by a health care professional.

Need CPT codes for other Merck vaccines?

CPT, Current Procedural Terminology.

Current Procedural Terminology©2019 American Medical Association. All Rights Reserved.

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