Make sure claims and documentation support medical necessity.

Healthcare providers have been given the go-ahead to provide an additional dose of the COVID-19 vaccine to certain patients. Here’s what you need to know for Medicare claims.

The U.S. Food and Drug Administration (FDA) amended the emergency use authorization for both the Pfizer BioNTech COVID-19 vaccine and the Moderna COVID-19 vaccine “to allow for an additional dose in certain immunocompromised people,” according to an MLN Connects Special Edition article issued Aug. 16.

According to the American Medical Association, (AMA) “Immunocompromised people account for at least 2.7% of U.S. adults — about 7 million people.”

Coding COVID-19 Boosters

The AMA has released CPT errata to account for one Category I code accepted by the CPT Editorial Panel and to update the effective date of another.

For the extra dose of the Pfizer vaccine, report CPT codes:

91300 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted, for intramuscular use

0003A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; third dose

The dosing regimen for the Pfizer vaccine is two doses of 0.3 mL each, three weeks apart. A third dose may be administered at least 28 days following the second dose to individuals 12 years and older who have undergone solid organ transplantation or who are diagnosed with conditions that make them equally immunocompromised.

For the extra dose of the Moderna vaccine, report CPT codes:

91301 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 100 mcg/0.5 mL dosage, for intramuscular use

0013A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose

The dosing regimen for the Moderna vaccine is two doses of 0.5 mL each, one month apart. A third dose may be administered at least 28 days following the second dose to individuals 18 years and older who have undergone solid organ transplantation or who are diagnosed with conditions that make them equally immunocompromised.

Tip: Double-check the code numbers before submitting claims. With so many new vaccine codes, some very similar to others, it would be easy to transpose one number. For example, you might mean to enter 0013A for the Moderna vaccine but accidentally enter 0031A for the Janssen vaccine instead. This is a simple and common mistake that would result in the claim being rejected for noncoverage.

Payment Rates for Vaccine Administration

The vaccination administration fee for an additional dose is the same as it is for the first two doses: approximately $40, effective March 15, 2021. Medicare will pay an additional $35 for administering the COVID-19 vaccine in the home for certain Medicare patients, and this payment also applies for additional doses administered in the home for qualified patients on or after Aug. 12, 2021. Report this service with CPT code M0201 COVID-19 vaccine home admin (in addition to the vaccine and admin codes).

UPDATE: Previous guidance from the Centers for Medicare & Medicaid Services allowed you to bill only 1 unit of M0201, regardless of the number of patients being vaccinated in a home, temporary lodging, or apartment. Per MLN Connects Special Edition, released Aug. 24, the definition of “qualified patients” has changed. Providers can now bill up to 5 units of M0201 in a communal space with fewer than 10 Medicare patients. For example, if a provider administers a third dose of the Pfizer COVID-19 vaccine to 10 Medicare patients on the same date and in the same location, you would bill Medicare 91301 x10, 0031A x10, and M0201 x5.

Note: Rates are geographically adjusted. Rates do not apply if Medicare pays your facility for preventive vaccines and their administration at reasonable cost.

Coverage for 0003A and 0013A is effective for claims on or after Aug. 12, 2021. However, Medicare Administrative Contractors will hold all claims until their systems are updated, no later than Aug. 27.

Reference:

https://www.aapc.com/blog/81734-covid-19-vaccine-boosters-covered-by-medicare/#respond