Primary Care Coding Alert

Reviewed on May 22, 2015

Question:

Medicare and private payers are denying Prevnar 13 (90670, Pneumococcal conjugate vaccine, 13 valent, for intramuscular use). What should we do?

Answer:

Pneumococcal vaccines fall under three vaccine product codes. Choose the correct code based on the product and patient's age (older or younger than 2 years of age).

For Prevnar 13 or PCV13 (pneumococcal Conjugate, 13 valent), use 90670 (Pneumococcal conjugate vaccine, 13 valent, for intramuscular use). The recommended vaccine schedule for Prevnar is that a patient receives the vaccine at ages 2 months, 4 months, 6 months, and 12-15 months.

The pneumococcal vaccines Pneumovax 23 and Pnu-Immune 23 both fall under 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use). These products are for patients 2 years of age to 65 plus years of age. Pneumovax (PPVSV) and Pnu-Immune are recommended for use in all adults who are older than 65 years of age and for persons who are 2 years and older and at high risk for disease (for instance, sickle cell disease, HIV infection, or other immuno-compromising conditions). They are also recommended for use in adults 19 through 64 years of age who smoke cigarettes or who have asthma.

Code 90670 only had its FDA approval pending indicator removed on Feb. 23, 2010. The code's revised status was printed in the CPT CPT^® 2011 manual.

Action: Contact payers and explain that Prevnar 13 is replacing Prevnar 7, which with 7 valents is coded as 90669 (Pneumococcal conjugate vaccine, 7 valent, for intramuscular use). Since Prevnar 13 has 13 valents, the correct code is 90670. This code now has FDA approval. Send the payers a copy of the AMA notice indicating the code's changed status (http://djk9qtinkh46n.cloudfront.net/ppdf/2010-category-I-vaccine-codes1.pdf ).