CPT 90732 - What is Pneumococcal vaccine - who are at risk

Vaccine Codes & Descriptors

90670 – Pneumococcal conjugate vaccine, 13-valent, 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

Frequency of Administration

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

Pneumococcal Vaccine Administration

Code: G0009 Diagnosis Code: Z23Administration & Diagnosis Codes                     

ACIP recommends that all persons receive a dose of pneumococcal vaccine when or after they reach age 65. Persons who receive a dose before age 65 are recommended to receive another dose after they turn age 65, once 5 years have elapsed since their prior dose. 

The pneumococcal vaccine is generally a once-in-a-lifetime after age 65 vaccination that can be given at any time during the year. All persons who have unknown vaccination status should receive one dose of vaccine. Pneumococcal vaccine may be administered at the same time as influenza vaccine (by separate injection in the other arm).

According to ACIP, pneumococcal vaccine is recommended for the following groups of persons who are at increased risk from invasive pneumococcal disease or its complications:

• Children less than 2 years of age (pneumococcal conjugate vaccine) and adults aged 65 or more (polysaccharide vaccine);

• Adults who have chronic cardiovascular diseases (e.g., congestive heart failure or cardiomyopathy), chronic pulmonary diseases (e.g., chronic obstructive pulmonary disease [COPD] or emphysema), or chronic liver diseases (e.g., cirrhosis);

• Adults with diabetes mellitus. Diabetes is associated with cardiovascular or renal dysfunction, both of which increase the risk for severe pneumococcal illness;

• Persons who have liver disease as a result of alcohol abuse;

• Persons with functional or anatomic asplenia (e.g., sickle cell disease or splenectomy). This group is at very high risk for pneumococcal infection, because this condition leads to reduced clearance of encapsulated bacteria from the bloodstream.

• Persons with cerebrospinal fluid (CSF) leakage resulting from congenital lesions, skull fractures, or neurosurgical procedures. These persons are at risk for recurrent pneumococcal meningitis;

• Persons who have decreased responsiveness to polysaccharide antigens or an increased rate of decline in serum antibody concentrations as a result of 

a) immunosuppressive conditions (e.g., congenital immunodeficiency, human immunodeficiency virus [HIV] infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, or generalized malignancy). S. pneumoniae is the most commonly identified bacterial pathogen that causes pneumonia in HIV-infected persons;

b) organ or bone marrow transplantation;

c) chemotherapy with alkylating agents, antimetabolites, or systemic corticosteroids;

d) systemic corticosteriods; or

e) chronic renal failure or nephrotic syndrome.

About 78% of adults who have invasive pneumococcal infection have at least one of the previously mentioned underlying medical conditions, including age greater than or equal to 65 years.

Because asthma has not been associated with an increased risk for pneumococcal disease, persons with asthma do not need pneumococcal vaccine unless they have asthma as part of chronic bronchitis or emphysema or they use long-term systemic corticosteriods.

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

Types of Pneumococcal Vaccines and Their Administration

HCPCS Code            Description

90669 Pneumococcal conjugate vaccine, 7 valent (PCV7), for intramuscular use

90670 Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use

G0009 Administration of the pneumococcal vaccine

90732 Pneumococcal polysaccharide vaccine, 23 valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use

Administration & Diagnosis Codes         Vaccine Codes & Descriptors          Frequency of Administration

Pneumococcal Vaccine Administration Code: G0009

Diagnosis Code: Z23

90670 – Pneumococcal conjugate vaccine, 13-valent, 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

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

Vaccine       Vaccine Code & Description        Administration Code  Diagnosis Code

Pneumococcal

90670 – Pneumococcal conjugate vaccine, 13 valent, 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

V03.82

V06.6 (Influenza & pneumococca l during same visit)

Suggestions for Smooth Third Party Reimbursement

All major payers in New Mexico reimburse pneumococcal vaccination.

Coding adult PPV-23:

* CPT-4 code 90732 (Pneumococcal Polysaccharide Vaccine, 23 Valent, Adult Dosage) with ICD-9 diagnosis V03.82 (Need for Pneumococcal Vaccination) on all claims.

* HCPC code G0009 (Administration of Pneumococcal Vaccine) on all Medicare and Medicare senior plan claims – this should be paid separately from any office visit charge.

* CPT-4 codes 90471 (Immunization Administration - One Vaccine) or 90472 (Immunization Administration – Each Additional Vaccine) with all other payers. We suggest you place CPT-4 modifier -25 after your evaluation and management code (99201-99215) to indicate it was unrelated to administration of pneumococcal vaccine.

Coding child/youth PPV-23:

* No source can be billed for the vaccine acquired from VFC. Claims should show the vaccine code (90732) with a zero ($0.00) charge, and the administration fee code (90465 or 90466) for children under eight with counseling, 90471 or 90472 for children eight and older or without counseling.

* The exception is the fee-for-service exempt Medicaid (not SALUD!) program. For exempt Medicaid patients, use only the CPT code for the vaccine (90732) and enter the usual charge for vaccine administration for it. Use diagnosis code V03.82 for PPV-23 vaccine and administration.

HCPCS Code              Description

90732

Pneumococcal polysaccharide vaccine, 23 valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use

METHODOLOGY

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.

Limitations

We did not determine the immunocompetence of beneficiaries; however, even for immunocompromised beneficiaries, revaccination is recommended no sooner than 5 years after the first vaccination. Of the 8,713,178 claims reviewed, a total of 662,085 claims—650,842 claims from 2007 and 11,243 claims from 2008—did not have a National Provider Identifier. 

Thus, 8 percent of claims could not be used to determine whether the corresponding vaccinations contributed to multiple vaccinations from the same provider. 

We could not determine whether the adverse events reported in VAERS resulted from first pneumococcal vaccinations or subsequent ones.

Standards

This study was conducted in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 

Table 2: Allowed Pneumococcal Vaccinations for Two or More Vaccinations of the Same Type for the Same Beneficiary for the Period 2007–2011

HCPCS Code Number of Repeat Vaccinations   Allowed Amount

90669 (PCV7) 33 $3,030

90732 (PPSV23) 125,822 $4,738,104

G0009 113,840 $2,239,386

 Total 239,695 $6,980,520

For beneficiaries who received repeat vaccinations of the same type for the period 2007–2011, 43 percent received repeat vaccinations from the same providers that gave the first vaccinations

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. See Table 3.

For HCPCS code 90732 (PPSV23), 122,474 beneficiaries received 125,822 repeat vaccinations, ranging from 2 to 14 vaccinations. Less than half (52,255) of the beneficiaries received repeat vaccinations from the same provider. The 24,983 providers we identified who gave repeat vaccinations gave between 1 and 754 beneficiaries repeat vaccinations. 

The previously mentioned Florida provider gave 41 beneficiaries repeat vaccinations. The provider responsible for the 754 beneficiaries was a home health provider located in Columbia, Maryland. See Table 3.

In total, for beneficiaries who received repeat pneumococcal vaccinations of the same type, 43 percent received repeat vaccinations from the same providers that gave the first vaccinations. 

Table 3: Individual Provider Ranking of Repeat Pneumococcal Vaccinations by Number of Beneficiaries Served for the Period 2007–2011

HCPCS Code           Number of Beneficiaries       Type of Provider         Location of Provider

90669 (PCV7) 

30 Allergy and Immunology North Palm Beach, FL

754 Home Health* Columbia, MD

431 Immunization Clinic* Scottsdale, AZ

214 Community Health Sarasota, FL

211 Community Health Opelika, AL

90732** (PPSV23)

185 Private Company Opelika, AL

171 Internal Medicine Teaticket, MA

145 County Health Department Leonardtown, MD

129 Family Medicine Orlando, FL

79 Internal Medicine Garden Grove, CA

57 Family Medicine Mount Vernon, IN