Monday, July 5, 2010

CPT 90732 , G0008, G0009- What is Pneumococcal vaccine - who are at risk

Immunization Procedure Codes & Descriptors (cont.) Administration & Diagnosis Codes Vaccine Codes & Descriptors Frequency of Administration Pne mococcal Vaccine Administration Code: G0009 

Diagnosis Code: Z23

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

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 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 and Seasonal Influenza Virus Vaccines received during the same visit


Administration Codes:

G0008: Influenz Virus 

G0009: Pneumococcal 

Diagnosis Code: Z23 Use seasonal influenza virus and pneumococcal vaccine codes

Follow Medicare coverage requirements for seasonal influenza virus and Pneumococcal vaccines



Pneumococcal Vaccine

Administration Code: G0009

Diagnosis Code: V03.82

90669 – Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use

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 Once in a lifetime/ Medicare may cover additional vaccinations based on risk

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.


Medicare Covered for Influenza and Pneumococcal Vaccines listed below are eligible for Medicare Part B payment. These vaccines may be reimbursed regardless of the setting in which they are furnished. In addition, the administration fee for these vaccines is also eligible for payment.

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


Age-Specific Vaccines

Certain vaccines specify age requirements that may be very specific (usually involving an age range), or more generic (usually indicating either pediatric, adolescent or adult). Coders must make sure the patient’s age and any vaccines reported do not contradict one another. The age-specific vaccines include the following: 90632, 90633, 90634, 90636, 90644, 90655, 90656, 90657, 90658, 90669, 90696, 90700, 90702, 90714, 90715, 90718, 90732, 90743 and 90744.

HCPCS Administration Codes When billing influenza, pneumonia or hepatitis B, the Centers for Medicare and Medicaid (CMS) require different administration codes than regular CPT® administration codes (90471-90474). The HCPCS administration codes and the vaccine codes have a one-to-one relationship and are always paired together. Rules for reporting initial or subsequent vaccines do not apply.

The HCPCS administration codes and the vaccines they are paired with are listed below:· G0008 - Influenza (Q2035 through Q2039)

· G0009 - Pneumonia (90732)
· G0010 - Hepatitis B (90746)

If other vaccines are combined with these four G-codes, the standard CPT® administration codes (90460-90461, 90471- 90474) must be used to track the remaining vaccines. Listed below are examples of vaccines for a Medicare claim and nonMedicare claim:

Vaccines Given: Flu (90658 or Q2036)

 Tetanus (90703)
 MMR (90707)
 HPV (90649)


Billing Guidelines with example

Modified Form CMS-1500 for Cover Document

Entities submitting roster claims to carriers must complete the following blocks on a single modified Form CMS-1500, which serves as the cover document for the roster for each facility where services are furnished. In order for carriers to reimburse by correct payment locality, a separate Form CMS-1500 must be used for each different facility where services are furnished. 

Item 1: An X in the Medicare block
Item 2: (Patient's Name): "SEE ATTACHED ROSTER"
Item 11: (Insured's Policy Group or FECA Number): "NONE"
Item 17A (I.D. Number or Referring Physician): This number is required for PPV  claims with dates of service prior to July 1, 2000. This number is also required for Hepatitis B vaccines.

Item 20: (Outside Lab?): An "X" in the NO block
Item 21: (Diagnosis or Nature of Illness):
Line 1: PPV = "V03.82", Influenza Virus: = "V04.8"
Effective for claims with dates of service on or after October 1, 2003, use
V04.81.

Item 24B: (Place of Service (POS)):
Line 1: "60"
Line 2: "60"

NOTE: POS Code '60" must be used for roster billing.

Item 24D: (Procedures, Services or Supplies):

Line 1:

PPV: "90732"

Influenza Virus: "90659"

Line 2:

PPV: "G0009"

Influenza Virus: "G0008"

Item 24E: (Diagnosis Code): Lines 1 and 2: "1"

Item 24F: ($ Charges): The entity must enter the charge for each listed service. If the entity is not charging for the vaccine or its administration, it should enter 0.00 or "NC" (no charge) on the appropriate line for that item. If your system is unable to accept a line item charge of 0.00 for an immunization service, do not key the line item. Likewise, electronic media claim (EMC) billers should submit line items for free immunization services on EMC PPV or influenza virus vaccine claims only if your system is able to accept them. 

Item 27: (Accept Assignment): An "X" in the YES block.

Item 29: (Amount Paid): "$0.00"

Item 31: (Signature of Physician or Supplier): The entity's representative must sign the modified Form CMS-1500.

Item 32: N/A

Item 33: (Physician's, Supplier's Billing Name): If the provider number is not shown on the roster billing form, the entity must complete this item to include the Provider Identification Number (not the Unique Physician Identification Number) or Group Number, as appropriate.


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