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Pneumococcal Vaccine Claims Processing Updates April 2022

The Pneumococcal Vaccine CPT codes will be payable by Medicare. The new codes will be in the 2021 Medicare Physician Fee Schedule Database file update and the annual HCPCS update. 

90677-  Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use.

  • Which is effective for Dates of Service (DOS) on or after July 1, 2021

90671 - Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use

  • Which is effective for DOS on or after July 16, 2021 

The CPT 90677 does not apply for Coinsurance and deductible.

A Medicare Administrative Contractor (MAC) will pay institutional providers for these codes based on the Type of Bill (TOB) used. The two payment methods are,

      1. The Medicare Administrative Contractor (MAC) will pay these institutional providers using reasonable cost if you use the following,

    • Hospitals (TOBs 12X and 13X)
    • Skilled Nursing Facilities (TOBs 22X and 23X)
    • Home Health Agencies (TOB 34X)
    • Hospital-based Renal Dialysis Facilities (RDFS) (TOB 72X)
    • Critical Access Hospitals (CAHs) (TOB 85X)
      2. A MACs will pay these institutional providers based on the lower of the actual charge or 95% of the Average Wholesale Price (AWP) if you use,
    • Comprehensive Outpatient Rehabilitation Facilities (TOB 75X)
    • Independent RDFs (TOB 72X)
    • Indian Health Services (IHS),
      • Hospitals (TOBs 12X and 13X)
      • Hospices (TOBs 81X and 82X)
      • IHS CAHs (TOB 85X)

A MAC will hold  the claims they get before April 1, 2022, for mentioned below CPT codes,

  • HCPCS code 90677 with DOS on and after July 1, 2021
  • HCPCS code 90671 with DOS on or after July 16, 2021

A MAC will process the claims when Medicare systems are ready on April 4, 2022. Also, your MAC will initiate a mass adjustment for any claims that rejected with HCPCS 90677 with a DOS from July 1, 2021 to September 30, 2021. 

They will also adjust rejected claims with HCPCS code 90671 with dates of service from July 16, 2021 to March 31, 2022. These adjustments will occur after April 4, 2022.

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