Updates to Pneumococcal Immunizations for Adults

(Update: CMS Claims Processing instructions were referenced in the coding for this bulletin. Level I of the HCPCS is comprised of Current Procedural Terminology (CPT-4), a numeric, uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.)

Effective for dates of service on or after Sept. 15, 2022, the South Carolina Department of Health and Human Services (SCDHHS) will expand coverage for additional pneumococcal immunizations for Healthy Connections Medicaid members 19 years of age and older under the pharmacy and medical benefit.

SCDHHS will reimburse providers for the administration of the immunizations in accordance with the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) Adult Immunization Schedule for the following Healthcare Common Procedure Coding System (HCPCS) codes: 

  • Pneumococcal 15-valent conjugate vaccine (PCV15): HCPCS Code 90671
  • Pneumococcal 20-valent conjugate vaccine (PCV20): HCPCS Code 90677

The new codes will be reflected on the Physicians Fee Schedule and updates to the Physicians Services provider manual will be available by Sept. 15, 2022.

Pharmacy reimbursement utilizes the standard basis of payment for the fee-for-service pharmacy benefit at the lowest of:

  • The actual acquisition cost (AAC) plus a professional dispensing fee (PDF) of $10.50;
  • The state’s maximum allowable cost plus a PDF of $10.50; or,
  • The usual and customary charges to the general public.

Coverage for children through 18 years of age will continue to be provided through the Vaccines for Children (VFC) program. SCDHHS will continue to reimburse for the administration of age-appropriate vaccinations provided to children when the vaccine is obtained through the VFC program.

Providers should direct any questions related to this bulletin to the Provider Service Center (PSC) at (888) 289-0709. The PSC’s hours of operation are 7:30 a.m. – 5 p.m. Monday – Thursday and 8:30 a.m. – 5 p.m. Friday. Questions regarding fee-for-service claims processing should be directed to Magellan Medicaid Administration’s Call Center at (866) 254-1669. The call center is available 24 hours/day. 

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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