COVID-19 Vaccine Boosters Covered by Medicare
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 (EUA) 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.
Note: This article was updated Sept. 22, 2021, to expand the EUA for the Pfizer vaccine booster.
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.
On Sept. 22, the FDA amended the EUA for the Pfizer-BioNTech COVID-19 vaccine to allow for use of a single booster dose “at least six months after completion of the primary series” in individuals:
- 65 years of age and older;
- 18 – 64 years of age and at high risk of severe COVID-19; and
- 18 – 64 years of age whose “frequent institutional or occupational exposure to SARS-CoV-2 puts them at high risk of serious complications of COVID-19.”
The FDA explains in a press release that “this includes healthcare workers, teachers, and daycare staff, grocery workers and those in homeless shelters or prisons, among others,” said Acting FDA Commissioner Janet Woodcock, MD.
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 “per home unit or communal space within a single group living location,” according to CMS.
CMS provides an infographic explaining proper billing of COVID-19 vaccination in the home, complete with coding and billing scenarios.
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.