DEPARTMENT OF HEALTH A.l\iD HUIY1fu'\J SERVICES 
OFFICE  OF INSPECTOR GENERAL 
\YASHI NGTON, DC  2020! 
JUH24 2013 
TO: 	 Marilyn Tavenner 
Adminis.trator 
Centers for Medicare & Medicaid Services 
FROM:  Stuart Wright 
Deputy Inspector General 
for Evaluation and Inspections 
SUBJECT: 	 Memorandum Report:  Repeat Pneumococcal Vaccinations for Medicare 
Beneficiaries, OEI -07-13-00310 
This memorandum report determines the number ofMedicare beneficiaries aged 65 years 
or older who received multiple pneumococcal vaccinations during a 5-year period 
(between 2007-2011) and the Medicare payments associated with those vaccinations. 
Current vaccination recommendations state that individuals without 
immunocompromising medical conditions should receive a single pneumococcal 
vaccination at the age of 65 years or older and individuals with immunocompromising 
conditions should receive a second vaccination 5 years after their first.  Medicare 
instructs providers to administer a pneumococcal vaccination if a beneficiary is uncertain 
of his or her vaccination history in the past 5 years.  Vaccination is intended to reduce the 
risk of contracting serious disease, but vaccination is not without risk.  In 2012, the 
Vaccine Adverse Event Reporting System (VAERS) , a national vaccine surveillance 
program, reported more than 1,000 adverse events associated with the 4.6 million 
pneumococcal vaccinations for Medicare beneficiaries between 2007 and 2011.  Using 
claims data, we reviewed the frequency ofpneumococcal vaccinations for beneficiaries 
age 65 and older without immunocompromising medical conditions to detect 
beneficiaries receiving vaccinations more frequently than recommended. 
SUMMARY 
The Advisory Committee on Immunization Practices (ACIP) makes recommendations on 
the frequency ofvaccinations.1  According to ACIP, individuals 65 years of age or older 
1 ACIP is a group of medical and public health experts that develops recommendations on vaccines use to 
control diseases in the United States.  The recommendations stand as public health advice.  ACIP was 
established under Section 222 of the Public Health Service Act (42 U.S.C.  217(a)).  Accessed at 
http://www.cdc.gov/vaccines/acip/a\2Qill.J!.1.Il)l on April 10, 2013.  Page 2  Marilyn Tavenner 
 
should receive a pneumococcal vaccination to prevent pneumonia.  For individuals other 
than those with certain immunocompromising medical conditions, one vaccination should 
be sufficient to confer immunity for a lifetime.  However, ACIP states that if more than 
one vaccination is given, they should be at least 5 years apart.  We found that 
122,498 beneficiaries received more than one pneumococcal vaccination of the same type 
within the 5-year period 20072011.  For beneficiaries who received repeat 
pneumococcal vaccinations of the same type, 43 percent received a repeat vaccination 
from the same provider who gave the first vaccination. 
 
BACKGROUND 
 
Pneumococcal disease is caused by the Streptococcus pneumoniae bacteria.  It is a 
leading cause of vaccine-preventable illness and death in the United States.  
Pneumococcal pneumonia kills about 4,000 people annually in the United States.2  
Although anyone can contract pneumococcal disease, some people are at greater risk of 
contracting the disease than others, such as people 65 years and older, the very young, 
people with weakened immune systems, and people with certain health conditions.3   
 
Pneumococcal infections can often be treated with antibiotics; however, some strains of 
the disease have become resistant, which makes prevention through vaccination even 
more important.4  Table 1 describes (1) the three vaccines that are used to prevent 
pneumococcal infections, (2) the Healthcare Common Procedure Coding System 
(HCPCS)5 codes for these vaccines, and (3) the HCPCS code associated with 
pneumococcal vaccine administration.  
   
                                                 
2 Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide 
Vaccine for Adults with Immunocompromising Conditions:  Recommendations of the Advisory Committee 
on Immunization Practices (ACIP), Morbidity and Mortality Weekly Report (MMWR) 61(40); 816-819,  
October 12, 2012.  Accessed at http://www.cdc.gov/mmwr/ on March 13, 2013.   
3 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 
Pneumococcal Polysaccharide Vaccine Information Statement, October 6, 2009. 
4 Ibid. 
5 HCPCS Level 1 numerical codes (e.g., 70405) are identical to CPT codes and are used by CMS when 
services and procedures involve Medicare beneficiaries.  The five character codes and descriptions 
included in this report are obtained from Current Procedural Terminology (CPT), copyright 2011 
by the American Medical Association (AMA).  CPT is developed by the AMA as a listing of 
descriptive terms and five character identifying codes and modifiers for reporting medical services 
and procedures.  Any use of CPT outside of this report should refer to the most current version of 
the Current Procedural Terminology available from AMA.  Applicable FARS/DFARS apply. 
Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310)  Page 3  Marilyn Tavenner 
 
Table 1:  Types of Pneumococcal Vaccines and Their Administration 
 
HCPCS 
  Description 
Code 
90669  Pneumococcal conjugate vaccine, 7 valent (PCV7), for intramuscular use 
 
90670  Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use 
 
Pneumococcal polysaccharide vaccine, 23 valent (PPSV23), adult or 
90732  immunosuppressed patient dosage, when administered to individuals 2 years 
or older, for subcutaneous or intramuscular use  
 
G0009    Administration of the pneumococcal vaccine 
 
Source:  Centers for Medicare and Medicaid Services.  Medicare Learning Network, Quick Reference Information:  
Medicare Immunization Billing (Seasonal Influenza Virus, Pneumococcal, and Hepatitis B), ICN 006799.  August 2012.   
 
Vaccine Recommendations 
 
PCV7.  PCV7 has been in use since 2000, and its use has resulted in significantly less 
pneumococcal disease from the seven strains against which the vaccine protects. 
 
PCV13.  PCV13 includes the seven serotypes in PCV7 plus six additional serotypes, 
including serotype 19A, which has become the most common pneumococcal serotype 
and is often resistant to antibiotics.6  In June 2012, ACIP recommended routine use of 
PCV13 for adults aged 19 years or older with immunocompromising conditions and 
certain other medical conditions that increase the risk of infections.7 
 
PPSV23.  PPSV23 includes 12 of the serotypes included in PCV13, plus 11 additional 
serotypes.  PPSV23 is recommended for all adults aged 65 or older and for those between 
the ages of 19 years and 64 years if they fall within a high-risk group.8   For 
immunocompromised persons, a one-time revaccination dose of PPSV23 is 
recommended 5 years after the first dose.9  All adults are eligible for a dose of PPSV23 
starting at age 65, regardless of previous PPSV23 vaccination, but at least 5 years should 
pass between doses of PPSV23.10  The CDCs Pink Bookits guide on 
vaccine-preventable diseasesstates that because of the lack of evidence of improved 
protection with multiple doses of pneumococcal vaccine, routine revaccination of 
                                                 
6 Centers for Disease Control and Prevention (CDC), PCV13 (Pneumococcal Conjugate) Vaccine  
for Parents.  Accessed at http://www.cdc.gov/vaccines/vpd-vac/pneumo/vac-faqs.htm on March 13, 2013.     
7 Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide 
Vaccine for Adults with Immunocompromising Conditions:  Recommendations of the Advisory Committee 
on Immunization Practices (ACIP), MMWR) 61(40); 816-819, October 12, 2012.  Accessed at 
http://www.cdc.gov/mmwr/ on April 10, 2013.   
8 Ibid. 
9 Ibid. 
10 Ibid. 
Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310)  Page 4  Marilyn Tavenner 
 
immunocompetent persons previously vaccinated with the PPSCV23 vaccine is not 
recommended.11 
 
Vaccination Risks 
Vaccination is intended to reduce the risk of contracting serious disease, but vaccination 
is not without risk.  The VAERS is a national vaccine surveillance program that contains 
information about adverse events that occur after administration of vaccines.12   A review 
of data from VAERS for 2012 shows 1,191 adverse events associated with the 4.6 million 
pneumococcal vaccinations for individuals aged 65 years or older that took place between 
2007 and 2011.  There were 391 emergency department visits, of which 42 resulted in 
hospitalization.  Twelve events were reported as life threatening.13    
 
Medicare Payment 
Medicare generally covers one pneumococcal vaccination for a beneficiary age 65 or 
older; however, Medicare instructs providers to administer a pneumococcal vaccination if 
a beneficiary is uncertain of his or her vaccination history in the past 5 years.  If a 
beneficiary is certain that more than 5 years have passed since his or her vaccination, 
revaccination is not appropriate unless the beneficiary is at highest risk.14  Medicare also 
pays for the administration of vaccinations.  Medicare allowed $234 million for 
pneumococcal vaccinations and their administration between 20072011. 
 
National Initiatives 
Care coordination was one of the six priority areas in the U.S. Department of Health and 
Human Services 2012 Annual Progress Report to Congress:  National Strategy for 
Quality Improvement in Health Care.15  The report states that care coordination is a 
conscious effort to ensure that all key information needed to make clinical decisions is 
available to patients and their providers.16  Patients commonly receive medical services, 
treatments, and advice from multiple providers in many different care settings.17  To 
assist in communicating medical information, HHS has distributed more than $4.5 billion 
in incentive payments to nearly 1,700 hospitals and approximately 74,000 physicians and 
other health professionals who are using certified electronic health record systems that 
improve patient safety and coordination of care.18 
 
   
                                                 
11 CDC, Pneumococcal Disease, Epidemiology and Prevention of Vaccine-Preventable Diseases 
(The Pink Book), May 2012.  Accessed at http://www.cdc.gov/vaccines/pubs/pinkbook/pneumo.html on 
April 10, 2013.    
12 Accessed at http://vaers.hhs.gov/index on April 4, 2013. 
13 Ibid. 
14 Centers for Medicare & Medicaid Services.  Medicare Learning Network, Quick Reference Information:  
Medicare Immunization Billing (Seasonal Influenza Virus, Pneumococcal, and Hepatitis B).  ICN 006799.  
August 2012.   
15 U.S. Department of Health and Human Services.  2012 Annual Progress Report to Congress:  National 
Strategy for Quality Improvement in Health Care.  August 2012.  Accessed at 
http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf on April 15, 2013. 
16 Ibid. 
17 Ibid. 
18 Ibid. 
Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310)  Page 5  Marilyn Tavenner 
 
METHODOLOGY 
 
Data Collection and Analysis 
We obtained all Medicare Part B claims from the National Claims History File for the 
period 20072011 for HCPCS codes 90669, 90670, 90732, and G0009.  We then limited 
our review to claims with: 
 
  a Medicare Status Code of 10indicates that age was the qualifier for Medicare 
eligibility, and 
 
  a diagnosis code of V03.82 or V06.6(i.e., diagnosis codes indicating vaccination 
against Streptococcus pneumoniae).   
We limited the period of review to 5 years (i.e., the period for which even 
immunocompromised beneficiaries should not be revaccinated) and allowed for one 
vaccination per type90669 (PCV7), 90670 (PCV13), and 90732 (PPSV23)per 
beneficiary.  Our calculations as to whether a given vaccination constituted a second (or 
greater) vaccination of the same type were based on the order of occurrence for each 
vaccination.  Finally, all claims reviewed were for beneficiaries aged 65 years or older.  
 
Limitations 
We did not determine the immunocompetence of beneficiaries; however, even for 
immunocompromised beneficiaries, revaccination is recommended no sooner than 
5 years after the first vaccination.  Of the 8,713,178 claims reviewed, a total of 
662,085 claims650,842 claims from 2007 and 11,243 claims from 2008did not have 
a National Provider Identifier.  Thus, 8 percent of claims could not be used to determine 
whether the corresponding vaccinations contributed to multiple vaccinations from the 
same provider.  We could not determine whether the adverse events reported in VAERS 
resulted from first pneumococcal vaccinations or subsequent ones. 
 
Standards 
This study was conducted in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
 
RESULTS 
 
From 20072011, Medicare allowed multiple pneumococcal vaccinations for more 
than 122,000 beneficiaries in outpatient settings   
Of the 4.6 million beneficiaries receiving a pneumococcal vaccination from 20072011, 
we identified 122,498 beneficiaries who received multiple pneumococcal vaccinations of 
the same type.  Medicare allowed a total of $234 million for pneumococcal vaccinations 
in outpatient settings, of which nearly $5 million was for two or more pneumococcal 
vaccinations of the same type for the same beneficiary within the 5-year period and more 
than $2 million was for administration of these vaccinations.  See Table 2.   
   
Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310)  Page 6  Marilyn Tavenner 
 
Table 2:  Allowed Pneumococcal Vaccinations for Two or More Vaccinations of the Same 
Type for the Same Beneficiary for the Period 20072011  
 
HCPCS Code  Number of Repeat Vaccinations  Allowed Amount 
90669 (PCV7)  33  $3,030 
90732 (PPSV23)  125,822  $4,738,104 
G0009  113,840  $2,239,386 
   Total  239,695  $6,980,520 
 
Source:  OIG analysis of claims data, 2013.  There were no repeat vaccinations for HCPCS code 90670 (PCV13). 
 
For beneficiaries who received repeat vaccinations of the same type for the period 
20072011, 43 percent received repeat vaccinations from the same providers that 
gave the first vaccinations  
For HCPCS code 90669 (PCV7), 32 beneficiaries received 33 repeat vaccinations.  (One 
beneficiary received three vaccinations, while all others received two.).  Only two 
beneficiaries received repeat vaccinations from different providers.  Each of the 
remaining 30 beneficiaries received repeat vaccinations from the same provider.  
Twenty-six beneficiaries received repeat vaccinations from the same North Palm Beach, 
Florida provider.  That same provider also provided one of two vaccinations for the two 
beneficiaries receiving vaccinations from multiple providers.  See Table 3. 
 
For HCPCS code 90732 (PPSV23), 122,474 beneficiaries received 125,822 repeat 
vaccinations, ranging from 2 to 14 vaccinations.  Less than half (52,255) of the 
beneficiaries received repeat vaccinations from the same provider.  The 24,983 providers 
we identified who gave repeat vaccinations gave between 1 and 754 beneficiaries repeat 
vaccinations.  The previously mentioned Florida provider gave 41 beneficiaries repeat 
vaccinations.  The provider responsible for the 754 beneficiaries was a home health 
provider located in Columbia, Maryland.  See Table 3. 
 
In total, for beneficiaries who received repeat pneumococcal vaccinations of the same 
type, 43 percent received repeat vaccinations from the same providers that gave the first 
vaccinations. 
 
 
   
Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310)  Page 7  Marilyn Tavenner 
 
Table 3:  Individual Provider Ranking of Repeat Pneumococcal Vaccinations by Number of 
Beneficiaries Served for the Period 20072011  
 
Number of 
HCPCS Code  Type of Provider  Location of Provider 
Beneficiaries 
90669 (PCV7)  30  Allergy and Immunology  North Palm Beach, FL 
754  Home Health*  Columbia, MD 
431  Immunization Clinic*  Scottsdale, AZ 
214  Community Health  Sarasota, FL 
211  Community Health  Opelika, AL 
185  Private Company  Opelika, AL 
90732** (PPSV23) 
171  Internal Medicine  Teaticket, MA 
145  County Health Department  Leonardtown, MD 
129  Family Medicine  Orlando, FL 
79  Internal Medicine  Garden Grove, CA 
57  Family Medicine  Mount Vernon, IN 
 
* This provider had multiple NPIs within the top 10 providers; results were combined. 
** Only the top 10 providers were listed for 90732 (PPSV23). 
Source:  OIG analysis of claims data, 2013.   
 
CONCLUSION 
 
The results of our analysis indicate that some providers are providing repeat 
pneumococcal vaccinations to Medicare beneficiaries aged 65 years and older and that 
Medicare is paying for vaccinations more often than recommended by CDC/ACIP.  We 
support CMS and CDC/ACIP in their vaccination goals and efforts, but the data suggest a 
need to educate certain providers about repeat vaccinations.  The data also suggest that 
43 percent of the unnecessary vaccination could be reduced through providers reviewing 
the medical histories of established patients.  Tools, such as electronic medical records, 
may assist in this effort.  
 
This report is being issued directly in final form because it contains no recommendations.  
If you have comments or questions about this report, please provide them within 60 days.  
Please refer to report number OEI-07-13-00310 in all correspondence. 
  
Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310)