CMS provides more information on patients’ eligibility for pneumonia vaccines

A change in Medicare reporting should make it easier to identify when a patient is eligible for a pneumococcal pneumonia vaccine (PPV), so you can get paid appropriately when you administer it.  

The update concerns beneficiary fee-for-service (FFS) eligibility transactions related to PPV codes (CPT 90670 for the first vaccine and CPT 90732 for the second). Beginning April 13, the Centers for Medicare & Medicaid Services (CMS) will return the dates of service (DOS) and institutional National Provider Identifier (NPI) for Part A or rendering NPI for Part B (depending on the type of provider that administered the service) for all such transactions.

Previously, after processing the Medicare FFS claim, the claims processing system grouped these two pneumonia vaccine codes and returned only a single “next eligible” date from the claims processing system to the data store used by Medicare FFS eligibility transactions. There was no way for the eligibility systems to differentiate between the initial vaccine code and the second vaccine code.

With this change, Medicare FFS will return eligibility transactions with information for both of these codes, so you may determine if the beneficiary already received either or both vaccines, as well as when, and from whom. In fact, Medicare FFS eligibility transactions will give you even more PPV details for each beneficiary, including up to 10 occurrences of historical PPV codes with NPI, and DOS. If you don’t see a DOS/NPI for a beneficiary, Medicare FFS didn’t pay a claim for a PPV service.

For more information, see the related Medicare Learning Network Matters article on the CMS website.

— Kent Moore, Senior Strategist for Physician Payment