Medicare Updates Part B Coverage for Pneumococcal Vaccinations

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  • February 16, 2015
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Medicare Updates Part B Coverage for Pneumococcal Vaccinations

by: Susan Theuns, PA-C, CPC, CHC
Consistent with recent Advisory Committee on Immunization Practices (ACIP) recommendations, the Centers for Medicare & Medicaid Services (CMS) has updated its coverage for Pneumococcal Vaccinations from a “once in a lifetime benefit” to a two vaccine benefit. The new coverage was effective February 2, 2014 and can be applied retroactively to appeal denials to September 19, 2014.
MLN Matters® Number: MM9051 explains that Medicare will now 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 (that is, 11 full months have passed following the month in which the last pneumococcal vaccine was administered).

Medicare now recommends an initial pneumonia vaccine using a 27-valent vaccine (Pneumovax) and the second vaccine 12 months later using the 13-valent vaccine (Prevnar-13).
A Medicare beneficiary may receive the vaccine without a physician’s order, and without physician supervision. Previously, Medicare only covered an initial revaccination for beneficiaries at high risk of serious pneumococcal disease, and revaccination for beneficiaries at highest risk of serious pneumococcal infection, “and those likely to have a rapid decline in pneumococcal antibody levels, provided that at least five years had passed since the previous dose of pneumococcal vaccine.”

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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