Now that a COVID-19 vaccine is approved, providers need to execute a medical billing and coding strategy to sustain vaccination efforts.
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For many providers, the end of the pandemic is in sight with the recent emergency use authorization of a COVID-19 vaccine. And while this may be true, it is just the start of a COVID-19 vaccine billing and coding strategy for healthcare organizations.
The US government has already started shipping doses of the Pfizer-BioNTech vaccine to healthcare organizations across the country, and federal leaders expect to send more government-acquired doses as they become available and as the Food and Drug Administration (FDA) approves more vaccines for emergency use.
While providers generally cannot bill payers for vaccine doses they receive for free, providers will be able to submit claims for the administration of the vaccine and, eventually, doses it purchases from drug manufacturers.
CODING THE COVID-19 VACCINE
Medical codes and guidelines for COVID-19 and related therapies did not exist a year ago, but with the global pandemic, healthcare industry leaders quickly adapted key medical code sets to account for the novel coronavirus.
For starters, the World Health Organization (WHO) developed an International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code for COVID-19: U07.1 COVID-19. The Centers for Disease Control and Prevention (CDC) adopted the code in March when the US government declared the COVID-19 pandemic a national public health emergency. The code became effective on April 1, 2020.
Since then, the Centers for Medicare and Medicaid Services (CMS) has developed over 20 International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) codes for documenting COVID-19 treatments and vaccines. Six of the codes are for vaccine administration and they include:
- XW013S6: Introduction of COVID-19 vaccine dose 1 into subcutaneous tissue, percutaneous approach, new technology group 6
- XW013T6: Introduction of COVID-19 vaccine dose 2 into subcutaneous tissue, percutaneous approach, new technology group 6
- XW013U6: Introduction of COVID-19 vaccine into subcutaneous tissue, percutaneous approach, new technology group 6
- XW023S6: Introduction of COVID-19 vaccine dose 1 into muscle, percutaneous approach, new technology group 6
- XW023T6: Introduction of COVID-19 vaccine dose 2 into muscle, percutaneous approach, new technology group 6
- XW023U6: Introduction of COVID-19 vaccine into muscle, percutaneous approach, new technology group 6
CMS states that the new procedure codes will “describe the introduction or infusion of therapeutics, including monoclonal antibodies and vaccines for COVID-19 treatment,” including vaccines like the one from Pfizer and BioNTech that requires two doses.
However, the agency also notes that for hospitalized patients, Medicare will pay for the COVID-19 vaccine and its administration separately from the Diagnosis-Related Group rate. As such, providers should use the appropriate Current Procedural Terminology (CPT) code when administering the vaccine to a Medicare beneficiary who is a hospital inpatient.
The American Medical Association (AMA) has already created CPT codes for reporting of COVID-19 vaccines. So far, the group has developed codes unique to the Pfizer-BioNTech vaccine, which has already received emergency use authorization, and a vaccine from biotechnology company Moderna, which is currently being reviewed for emergency use authorization by the FDA.
AMA has assigned Category I code 91300 to the Pfizer-BioNTech vaccine and code 91301 to the Moderna.
To document the administration of the vaccines, AMA has also created codes 0001A, 0002A, 0011A, and 0012A.
Code 0001A describes the administration of the first dose of the Pfizer-BioNTech vaccine, while 0002A describes the second dose of the vaccine.
Providers who administer the Moderna vaccine when it is approved for emergency use can use 0011A for the first dose and 0012A for the second dose.
The codes are effective when the vaccine receives emergency use authorization or approval from the FDA.
REIMBURSEMENT FOR ADMINISTERING A VACCINE
With the proper coding and documentation, providers can get reimbursed for acquiring and administering the COVID-19 vaccine to patients.
For example, CMS has stated that it will provide Medicare reimbursement for COVID-19 vaccines and their administration as long as the vaccines are authorized for emergency use or approved by the FDA. The agency will reimburse providers under Medicare Part B, rather than Part D, to ensure broad coverage of the vaccine.
Medicare plans to pay providers 95 percent of the average wholesale price of the vaccine as it does with the influenzas and pneumococcal vaccines covered under Part B.
However, providers cannot bill Medicare for vaccines they receive for free from the government, CMS states.
In light of the policy, CMS has set payment allowances of $0.10 for both the Pfizer-BioNTech and Moderna vaccines is $0.10, respectively. The agency plans to update the payment allowance at a later date when organizations start to incur costs for the vaccine products.
For the administration of the vaccines, the payment allowances are currently $16.94 for the first dose of a vaccine (CPT codes 0001A and 0011A) and $28.39 for the second dose (CPT codes 0002A and 0012A). CMS notes that these rates will also be geographically adjusted in 2020 and 2021.
Vaccines that require a single dose will be reimbursed at a rate of $28.39.
Additionally, if providers administer the vaccine during a “significant, separately identifiable evaluation and management (E/M) service, such as an office visit,” they can document the work and report an E/M code in addition to vaccine and administration codes, the American Academy of Family Physicians advises.
Medicaid will also reimburse providers for COVID-19 vaccines and shot administration, and the programs must compensate Medicaid providers for an administration fee or office visits, even if the vaccine is free to patients, according to an interim final rule effective during the public health emergency.
Medicaid reimbursement rates will vary by state and type of arrangement, for example, fee-for-service or managed care.
Reimbursement rates will also 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.
The Trump Administration has said that Medicare’s payment rates are considered a reasonable rate for any COVID-19 preventative services, including vaccine administration.
Finally, for uninsured patients, providers can seek reimbursement for the vaccine and administration through the Provider Relief Fund, which is covering COVID-19 care for the uninsured. They will generally be reimbursed at Medicare rates, subject to available funding, according to the Provider Relief Fund website.
BILLING FOR THE VACCINE, ADMINISTRATION
To bill Medicare for COVID-19 vaccine shot administration, providers can either submit a single claim or via roster billing for multiple patients, CMS says.
Providers must administer shots to at least five patients on the same date of service to submit claims via rostering billing, unless the institution is an inpatient hospital, the agency adds. For institutional claims, specifically, the following types of bills are valid for roster billing:
- 12X, Hospital Inpatient
- 13X, Hospital Outpatient
- 22X, Skilled Nursing Facility (SNF) covered Part A stay (paid under Part B) and Inpatient Part B
- 23X, SNF Outpatient
- 34X, Home Health (Part B Only)
- 72X, Independent and Hospital-based Renal Dialysis Facility
- 75X, Comprehensive Outpatient Rehabilitation Facility
- 81X, Hospice (Non-hospital)
- 82X, Hospice (Hospital)
- 85X, Critical Access Hospital
Providers need to be enrolled in Medicare to bill the public payer for COVID-19 vaccine administration. Although, providers participating in a Medicare Advantage plan should submit claims to traditional Medicare for all patients enrolled in the plan in 2020 and 2021, CMS states.
For providers seeking reimbursement for uninsured patients, they can request claims reimbursement electronically via the COVID-19 Uninsured Program Portal. The Portal will only accept claims submitted using an 837 EDI transaction set.
Billing processes for state Medicaid programs and private payers will vary. Providers should communicate with a plan’s designated point-of-contact for details on how to submit claims for the COVID-19 vaccine and administration.