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 of pneumococcal 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 of vaccinations. 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. 
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Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310) 

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 2007–2011. 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.
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Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310) 

Table 1: Types of Pneumococcal Vaccines and Their Administration

HCPCS 

Code Description

90669 Pneumococcal conjugate vaccine, 7 valent (PCV7), for intramuscular use

90670 Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use

90732

G0009 Administration of the pneumococcal vaccine

Pneumococcal polysaccharide vaccine, 23 valent (PPSV23), adult or

immunosuppressed patient dosage, when administered to individuals 2 years

or older, for subcutaneous or intramuscular use

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 CDC’s “Pink Book”—its guide on 

vaccine-preventable diseases—states 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.
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Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310) 

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 2007–2011. 

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.
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Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310) 

METHODOLOGY

Data Collection and Analysis

We obtained all Medicare Part B claims from the National Claims History File for the 

period 2007–2011 for HCPCS codes 90669, 90670, 90732, and G0009. We then limited 

our review to claims with: 

• a Medicare Status Code of 10—indicates 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 type—90669 (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 claims—650,842 claims from 2007 and 11,243 claims from 2008—did 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 2007–2011, 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 2007–2011, 

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. 
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Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310) 

Table 2: Allowed Pneumococcal Vaccinations for Two or More Vaccinations of the Same 

Type for the Same Beneficiary for the Period 2007–2011 

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 

2007–2011, 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. 
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Repeat Pneumococcal Vaccinations for Medicare Beneficiaries (OEI-07-13-00310) 

Table 3: Individual Provider Ranking of Repeat Pneumococcal Vaccinations by Number of 

Beneficiaries Served for the Period 2007–2011 

HCPCS Code Number of 

Beneficiaries Type of Provider Location of Provider

90669 (PCV7) 30 Allergy and Immunology North Palm Beach, FL

90732** (PPSV23)

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

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.