Code COVID-19 Vaccines With Confidence
During this initial outlay of vaccine for the novel coronavirus, quality data is essential.
On Jan. 21, 2020, the United States was just learning about the threat of a novel coronavirus — severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) — and the disease it causes, named shortly thereafter coronavirus disease 2019 (COVID-19). A month later, there were 14 confirmed cases in the states with no reported deaths. Fast forward to Jan. 21, 2021: In our country alone, approximately 25 million people had tested positive for COVID-19, and more than 416,000 people had died from complications related to the virus.
“What a difference a day makes” is an understatement when you consider that an average of 1,074 people died from COVID-19 every day in the United States in 2020.
The government and private industry worked together at warp speed to produce a vaccine to stop the spread of COVID-19. Vaccinations began on Dec. 14, 2020, and at the time of this writing, there were two vaccines approved by the U.S. Food and Drug Administration (FDA) under the Emergency Use Authorization (EUA) policy. Individuals 65 years of age and older, high-ranking government officials, and healthcare workers were the first in line for the vaccine, and as of Jan. 21, 2021, more than 17.5 million people had received their first round of vaccinations.
As physician practices, healthcare facilities, and other approved entities prepare for widespread vaccinations, make sure your understanding of COVID-19 vaccination is up to date, so you are ready to process these claims correctly.
COVID-19 Vaccine Coverage
The Coronavirus Aid, Relief, and Economic Security (CARES) Act includes provisions that establish coverage for COVID-19 vaccines and their administration without any cost-sharing for patients (Sec. 3713 specifically addresses coverage under Part B). During the public health emergency (PHE), everyone in the United States may receive a COVID-19 vaccine free of charge.
Note: Effective Jan. 21, 2021, the Health and Human Services secretary extended the PHE determination of Jan. 31, 2020, another 90 days, to April 20, 2021. This marks the fourth extension of the COVID-19 PHE.
Providers are compensated for the administration of the vaccine only — the product is presently free. Merit-Based Incentive Payment System (MIPS) eligible clinicians may earn additional compensation through successful participation in the COVID-19 clinical data reporting improvement activity. The Centers for Medicare & Medicaid Services (CMS) has indicated that it will update the payment allowance for COVID-19 vaccines after the PHE expires.
COVID-19 Vaccine Codes and Payment Allowances
At the time of this writing, there are two vaccine products approved under the FDA’s EUA and two other vaccine products (AstraZeneca and Janssen) under review.
Accordingly, the American Medical Association’s CPT® Editorial Panel has approved 11 Category I codes for these COVID-19 immunizations, shown in Table A. The rates include the additional resources required for public health reporting, conducting outreach and patient education, and the time spent answering patients’ questions about the vaccine.
CMS has published the corresponding payment rates for COVID-19 vaccines and administration for Medicare providers and suppliers, as shown in Table B.
CMS’ COVID-19 Vaccine: Health Insurance Issuers and Medicare Advantage Plans toolkit, last updated Jan. 7, 2021, contains a long list of issues that payers/plans need to consider and address in order to provide coverage and reimbursement for vaccine administration. Providers administering COVID-19 vaccines will find a great deal of information that applies to them, as well.
The Toolkit states, for example, “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.”
In fact, CMS states in the toolkit, “Issuers are required, during the PHE, to cover the vaccine administration fee with zero cost sharing both in and out of network. Issuers are not required to add vaccine providers to their networks ….”
Vaccination Administration Guidelines
For the Pfizer-BioNTech COVID-19 vaccine, the interval is 21 days between the first and second doses. This multiple-dose vial contains a volume of 0.45 mL, which must be thawed and diluted prior to administration using 1.8 mL of 0.9 percent sodium chloride (not included). After dilution, one vial contains six doses of 0.3 mL. An FDA Fact Sheet for Healthcare Providers Administering Vaccine states, “If the amount of vaccine remaining in the vial cannot provide a full dose of 0.3 mL, discard the vial and content.”
For the Moderna COVID-19 vaccine, the interval is 28 days between the first and second doses, according to an FDA Fact Sheet.
The FDA issued an EUA for the Janssen COVID-19 vaccine on Feb. 27. This vaccine is recommended for use in individuals 18 years of age and older. According to an FDA fact sheet, this vaccine “is a suspension for intramuscular injection administered as a single dose (0.5 mL).”
AstraZeneca’s vaccine is not approved in the United States (at press time), so the FDA has not released any guidance for this product.
Conditions of Emergency Use Authorization
Vaccine administration must be furnished consistent with the FDA’s EUA. For example, the Moderna COVID-19 vaccine is indicated for use only in individuals 18 years of age and older. Providers administering this vaccine also must:
- Give patients receiving the Moderna COVID-19 vaccine information consistent with the company’s Fact Sheet for Recipients and Caregivers prior to the patient receiving the vaccine.
- Provide a vaccination card to the patient receiving the Moderna COVID-19 vaccine or their caregiver with the date to return for the second dose of the vaccine.
- Provide the Centers for Disease Control and Prevention’s v-safe information sheet to the patient receiving the Moderna COVID-19 vaccine or their caregiver.
Tip: V-safe is a new voluntary smartphone-based tool that uses text messaging and web surveys to check in with vaccine recipients.
Vaccination providers enrolled in the federal COVID-19 Vaccination Program must report to the Vaccine Adverse Event Reporting System all vaccine administration errors, all serious adverse events, cases of multisystem inflammatory syndrome (MIS) in adults and children, and cases of COVID-19 that result in hospitalization or death following administration of a COVID-19 vaccine.
See the Fact Sheet for Healthcare Providers Administering Vaccine (Vaccination Providers) for all EUA requirements.
CPT® Category I Vaccine Codes
At the time of this writing, the CPT® Editorial Panel has released four new COVID-19 vaccine codes. Each vaccine product has its own code. Although the vaccine maker is not listed in the descriptors, it is essential for coders to select the code that correctly identifies the vaccine product administered.
91300 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use
91301 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use
91302 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use
91303 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use
To help coders select the right code, providers should document the vaccine manufacturer, dosage, and whether it is the patient’s first or second dose (Remember: Janssen’s vaccine is a single dose).
Tip: Codify® by AAPC provides additional information coders need to code correctly, including drug manufacturer names and other pertinent information left out of code descriptors and guidelines.
CDC COVID Data Tracker, retrieved Jan. 21, 2021: https://covid.cdc.gov/covid-data-tracker/#cases_casesper100klast7days and https://covid.cdc.gov/covid-data-tracker/#vaccinations
FDA Fact Sheet for Healthcare Providers Administering Vaccine: https://www.fda.gov/media/144413/download and https://www.fda.gov/media/144637/download
CARES Act: https://www.congress.gov/116/bills/hr748/BILLS-116hr748enr.pdf