With the recent announcement of multiple COVID-19 vaccine trials and approvals, providers need to execute a medical billing and coding strategy to sustain vaccination efforts. Temporary billing guidance due to the COVID-19 PHE (Public Health Emergency) has been changing rapidly. This document is therefore a living document and may be updated as changes are made to the laws and regulations guiding treatment, billing and payment for services.
Medicare Coverage and Reimbursement
The CARES Act includes a provision that establishes Part B coverage for COVID-19 vaccines and their administration without any cost-sharing. Because it will be covered under Part B, the COVID vaccine and its administration will not be covered under Part D.
CMS released a toolkit on COVID-19 Vaccines located at https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf for reference.
Important things to remember:
Providers need to be enrolled in Medicare to bill the public payer for COVID-19 vaccine administration.
Medicare Advantage Coverage and Reimbursement: For Calendar Years (CYs) 2020 and 2021, Medicare payment for the COVID-19 vaccine and its administration for beneficiaries enrolled in Medicare Advantage plans will be made through the original fee-for-service Medicare program. Contracted providers should submit claims for administering the COVID-19 vaccine to the original CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved.
Providers that receive the COVID-19 vaccine free from the federal government are prohibited from seeking reimbursement from consumers for vaccine administration costs – whether as cost sharing or balance billing.
Medicare payment rates for COVID-19 vaccine administration will be $28.39 to administer single-dose vaccines. For COVID-19 vaccines requiring a series of 2 or more doses, the initial dose(s) administration payment rate will be $16.94, and $28.39 for the administration of the final dose in the series. These rates recognize the costs involved in administering the vaccine, including the additional resources involved with required public health reporting, conducting important outreach and patient education, and spending additional time with patients answering any questions they may have about the vaccine. These rates will also be geographically adjusted. * Since it is anticipated that providers, initially, will not incur a cost for the product, CMS will update the payment allowance at a later date. Providers should not bill for the product if they received it for free.
Medicaid, CHIP, and BHG Coverage and Reimbursement
Medicaid coverage of COVID-19 vaccines and their administration, without cost sharing, is expected to be available for most Medicaid beneficiaries through the end of the quarter in which the COVID-19 PHE ends. States have significant discretion in determining vaccine administration reimbursement rates that are paid to qualified providers that have a provider agreement with the Medicaid agency.
CMS released a guidance document located at https://www.medicaid.gov/state-resource-center/downloads/covid-19-vaccine-toolkit.pdf for reference.
Important things to remember:
Medicaid reimbursement rates will vary by state and type of arrangement, for example, fee-for-service or managed care.
As CMS expects that the initial supply of COVID-19 vaccines will be federally purchased, states would not be expected to provide Medicaid coverage and reimbursement for the vaccine itself.
States are not required to provide coverage for vaccine administration for certain beneficiaries receiving limited benefit packages. HRSA COVID-19 Claims Reimbursement is available for reimbursement of COVID-19 vaccine administration costs for individuals receiving Medicaid coverage for only limited benefit packages.
For facility services, such as hospitals, nursing facilities, FQHCs, and Indian Health Service and tribal facilities, vaccine administration is usually included within the prospective payment system (PPS) or per diem rate applicable to services provided at the facilities.
The Pfizer-BioNTech vaccine is recommended for those age 16 and over. Approval of a vaccine for children under age 16 is expected in 2021.
Private Insurance Coverage and Reimbursement
Reimbursement rates will vary among private payers, but federal regulations also require the payers to cover COVID-19 vaccines and administration even if they are provided through an out-of-network provider.
Important things to remember:
Providers that administer vaccinations to patients without health insurance or whose insurance does not provide coverage of vaccination administration fees, may be able to file a claim with the provider relief fund, but may not charge enrollees directly for any vaccine administration costs.
The AMA released the table below to provide necessary coding guidance for vaccine administration services. This table links the individual severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine product codes (91300, 91301, 91302) to their associated immunization administration codes (0001A, 0002A, 0011A, 0012A, 0021A, 0022A), manufacturer name, vaccine name(s), 10 and 11-digit National Drug Code (NDC) Labeler Product ID, and interval between doses. These codes are also located in the Medicine section of the CPT code set. Additional introductory and instructional information for codes 0001A, 0002A, 0011A, 0012A, 0021A, 0022A, 91300, 91301, and 91302 can be found in the Immunization Administration for Vaccines/Toxoids and Vaccines, Toxoids guidelines in the Medicine section of the CPT code set. Please note that although codes are provided for the Astra Zeneca vaccine, it is still in the clinical trials phase in the United States.
COVID-19 vaccine services provided in an office setting are billed with ICD 10 code Z23 (Encounter for immunization)