SPECIAL BULLETIN COVID-19 #147: Moderna COVID-19 Vaccine (N/A) HCPCS code 91301: Billing Guidelines

The following information is only for non-long-term care providers who have the means to handle the specific storage recommendations required of the Moderna COVID-19 vaccine and will be administering it. This is the first general communication regarding the COVID-19 vaccine. NC Medicaid will issue subsequent guidance regarding specific vaccination programs and/or specific FDA approved vaccines as information becomes available. 

The CDC has released Interim Guidance for Immunization Services During the COVID-19 Pandemic. This guidance is intended to help immunization providers in a variety of clinical and alternative settings with the safe administration of vaccines during the COVID-19 pandemic.

If you have any questions about product specific information, please contact the Immunization Branch Help Desk at 1-877-873-6247 and press option ‘6.’ If you have any questions about billing NC Medicaid, please call the GDIT Call Center at 1-800-688-6696.

For Medicaid and NC Health Choice Billing

• The ICD-10-CM diagnosis code required for billing is:  Z23 - Encounter for immunization
• Providers must bill with HCPCS code: 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
• One Medicaid and NC Health Choice unit of coverage is: 0.5 mL
• The maximum reimbursement rate per unit is: N/A
• Providers must bill 11-digit NDCs: 80777-0273-10, 80777-0273-99
• The NDC units should be reported as "UN1"
• The fee schedule for the PADP is available on Medicaid's PADP web page.

Important Claims Information

• Medicaid and NC Health Choice will reimburse at the Medicare approved COVID-19 vaccination administration rate at first dose $16.94 and second dose $28.39.
• Claims must have appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code.
• Claims must contain both administration codes and vaccine codes to pay.
• Vaccine codes should be reported as $0.00.
• Claims for first vaccine dose must have been processed in NCTracks prior to processing a claim for second dose. 
• Medicaid and NC Health Choice do not allow copays to be charged for COVID-19 immunization or administrations.
• COVID-19 vaccines are exempt from the Vaccines for Children (VFC) program.
• TJ modifier should be used for NC Health Choice claims (age 6 through 18 years).
• EP modifier should be used for all non-NC Health Choice (only Medicaid beneficiaries) younger than 21 years of age.
• CG modifier should be used for claims submitted by a pharmacy participating in the immunization program for both the vaccine and administration codes (EXCEPTION: CVS/Walgreens pharmacies participating in the Long-Term Care immunization program for beneficiaries residing at the participating LTC facilities).

COVID-19 Vaccine Billing Codes for Medicaid and NC Health Choice Beneficiaries

Administration CPT Codes to Bill

Vaccine CPT Code to Report

Contact

NCTracks Contact Center: 800-688-6696