Infections Advisory Committee FAQ: Pneumococcal Vaccination Coverage


On August 13, 2014, the Advisory Committee on Immunization Practices (ACIP) met and approved changes to their recommendations for pneumococcal vaccination. Of note, the ACIP now recommends the routine use of 13-valent pneumococcal conjugate vaccine (PCV 13) in adults ≥ 65 years of age in addition to the 23-valent pneumococcal polysaccharide vaccine (PPSV23).1

AMDA has received a number of inquiries regarding questions of policy coverage owing to the complexity of the changes. This FAQ document is meant to assist members with questions concerning Medicare’s
pneumococcal vaccine coverage directives. Members are encouraged to consult with their individual carriers should they have additional questions.

Frequently Asked Questions About Pneumococcal Vaccination Coverage

  1. Is Pneumococcal Vaccination Covered By Medicare And It's Contractors? - YES.
    Pneumococcal Vaccination is covered under Part B benefits.2 CMS refers to ACIP recommendations as a "should" recommendation (which means "do") and so Medicare and all of it's contractors will cover pneumococcal vaccination as a Part B benefit. It is important to note that for coverage purposes, pneumococcal vaccines should be administered one year apart. Per the CMS Official Change Request 9051 Memo December 31, 2014. Medicare will cover:

    “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).”

    Clinicians are advised to review the ACIP pneumococcal vaccination guidelines for more information regarding the timing of vaccination from a clinical perspective.

  2. Will Medicare Or CMS Contractors Perform Searches On Claims Or Adjust Claims For Pneumococcal Vaccinations?
    CMS has updated the Medicare Claims Processing Manual to specify that "Contractors shall not search for and adjust any claims for pneumococcal vaccines and their administration, with dates of service on and after September 19, 2014. However, contractors may adjust claims brought to their attention." So, unless a provider would request a search on an individual Medicare recipient, no payment adjustments will occur.3,4
  3. What Should We Do If The Patient's Vaccination Status Is Unknown?
    In the past, ACIP guidance has been to offer vaccination if the patient's pneumococcal vaccine status is unknown. CMS has stated that providers should be able to determine vaccination status through use of electronic medical records. Unfortunately, this assumption is in error. While some information from individual electronic systems may be available to a provider for patients within a given health network or care setting, it is well documented that information flow from one provider's or health system's electronic records will not be transferred or accessible to another system. Thus, it is highly likely that a provider, particularly those managing patients with cognitive impairment or limited health literacy, will not be reasonably able to determine vaccination status. Given that CMS has directed it's contractors to not perform audits, considering the significant public and personal health benefits of pneumococcal vaccination, and recognizing that excessive efforts to determine vaccination status will result in inappropriate care delays, providers are advised to offer pneumococcal vaccination, in accordance with ACIP guidelines, in those instances where vaccination status cannot be determined in a timely fashion due to patient uncertainty and lack of access to past medical records.

    Below is the wording taken directly from the CMS Official Change Request 9051 Memo December 31, 2014:4

    "Those administering the vaccine should not require the patient to present an immunization record prior to administering the pneumococcal vaccine, nor should they feel compelled to review the patient’s complete medical record if it is not available. Instead, provided that the patient is competent, it is acceptable to rely on the patient’s verbal history to determine prior vaccination status."

  4. Is A Physician Or Advanced Practice Provider's Order Required To Administer A Pneumococcal Vaccination?


    For Medicare coverage, a physician order is not necessary. CMS has also clarified that a physician order is not necessary in hospital, nursing facility, or home
    health settings. Below is the wording from the CMS Official Change Request 9051 December 31, 2014 regarding coverage.4

    "Medicare does not require for coverage purposes that a doctor of medicine or osteopathy order the vaccine. Therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision."

Where Can I Learn More?

  1. CDC. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Recommendations of the Advisory
    Committee on Immunization Practices (ACIP) MMWR
    September 19, 2014;63(37):822-825.
  2. MLN Matters MM9051 December 31, 2014 
  3. Medicare Claims Processing Manual Transmittal Update 3159 December 31, 2014
  4. Official CMS Change Request 9051
  5. CMS Survey and Certification Memo October 10, 2002 (S&C-03-02)

Information accessed June 1, 2015.
Created 04 30 2015
Last updated 06 01 2015

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