SPECIAL BULLETIN COVID-19 #148: Pfizer-BioNTech COVID-19 Vaccine (N/A) HCPCS Code 91300: Billing Guidelines

Wednesday, January 6, 2021

This bulletin is for providers (Physicians, Physician Assistants, and Nurse Practitioners) and Local Health Departments.

This information is for the Pfizer COVID-19 vaccine only.

This is the first general communication regarding billing guidelines for the COVID-19 vaccine. Medicaid will issue subsequent information related to the guidance of specific vaccination programs and/or specific U.S. Food and Drug Administration (FDA) approved vaccines as information becomes available. 

Effective with date of service Dec 12, 2020, the Medicaid and NC Health Choice programs cover Pfizer-BioNTech COVID-19 Vaccine for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 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.

Strength/Package Size(s): Injection: Pfizer-BioNTech COVID-19 Vaccine is a preservative-free, frozen suspension for injection in a multiple dose vial.

Pfizer-BioNTech COVID-19 Vaccine is authorized for use under an Emergency Use Authorization (EUA) for active immunization to prevent coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in individuals 16 years of age and older.

Recommended Dose:  

  • The Pfizer-BioNTech COVID-19 Vaccine is administered intramuscularly as a series of two doses (0.3 mL each) three weeks apart.
  • Individuals who have received one dose of Pfizer-BioNTech COVID-19 Vaccine should receive a second dose of Pfizer-BioNTech COVID-19 Vaccine to complete the vaccination series.  
    • Vaccine products from different manufacturers are not interchangeable. 

The Centers for Disease Control and Prevention (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 NCTracks Contact 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: 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
  • One Medicaid and NC Health Choice unit of coverage is: 0.3 mL 
  • The maximum reimbursement rate per unit is: N/A
  • Providers must bill 11-digit NDCs: 59267-1000-01, 59267-1000-02, 59267-1000-03
  • 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 1st dose $16.94 and 2nd 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 1st vaccine dose must have been processed in NCTracks prior to processing a claim for 2nd dose  
  • Medicaid and NC Health Choice does 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 long-term care facility).

COVID-19 Vaccine Billing Codes for Medicaid Beneficiaries

Vaccine CPT Codes to Report

Vaccine CPT Code to Report

NDC

CPT Code Description

91300

59267-1000-01,
59267-1000-02,
59267-1000-03

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

 

 

 

 

 

Administrative CPT Codes to Bill

Administration CPT Code(s) to Bill

CPT Code Description

0001A

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/0.3mL dosage, diluent reconstituted; first dose

0002A

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/0.3mL dosage, diluent reconstituted; second dose

 

 

 

 

 

 

Contact

NCTracks Contact Center: 800-688-6696