Medicare instructs contractors to cease local pneumococcal vaccination frequency edits

The Centers for Medicare & Medicaid Services (CMS) recently discovered that some Medicare administrative contractors (MACs) had local pneumococcal vaccination frequency edits, such as lifetime and time elapsed between vaccinations, resulting in the inappropriate denial of claims. As a result, CMS issued instructions to all MACs on September 13, 2019, directing them to stop any local frequency editing within five business days (i.e., by September 20, 2019). If you believe you have claims inappropriately denied by such edits, you can resubmit the claims if the date of service is within Medicare’s timely filing limits. Otherwise, you will need to request a reopening.

— Kent Moore, Senior Strategist for Physician Payment at the American Academy of Family Physicians