Special Medicaid Bulletin COVID-19 #152: Billing Guidance for COVID-19 Vaccines

(PFIZER-BioNTech COVID-19 Vaccine HCPCS code 91300; Moderna COVID-19 Vaccine HCPCS code 91301)

The following information is only for pharmacies administering vaccines outside of the CVS/Walgreens Long-Term Care program who have the means to handle the specific storage recommendations required of the COVID-19 vaccine and will be administering it. 

The COVID-19 vaccines are 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).  Effective with date of service listed below, the Medicaid and NC Health Choice programs cover for use in the Physician Administered Drug Program (PADP):

• Dec. 12, 2020, Pfizer-BioNTech COVID-19 Vaccine: 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 in individuals 16 years of age and older.
• Dec. 21, 2020, Moderna COVID-19 Vaccine (N/A): 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 in individuals 18 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.  
• The Moderna COVID-19 Vaccine is administered intramuscularly as a series of two doses (0.5 mL each) 1 month apart.  Individuals who have received one dose of the Moderna COVID-19 Vaccine should receive a second dose of the Moderna COVID-19 Vaccine to complete the vaccination series.

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 (877) 873-6247 and press option 6. 

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
  • 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 unit of coverage is:
  • 0.3 mL for Pfizer vaccine
  • 0.5 mL for Moderna vaccine
• The maximum reimbursement rate per unit is: N/A (federally supplied)
• Providers must bill 11-digit NDCs:
  • Pfizer vaccine: 59267-1000-01, 59267-1000-02, 59267-1000-03
  • Moderna vaccine: 80777-0273-10, 80777-0273-99
• The NDC units should be reported as "UN1"
• The fee schedule for the PADP is available on NC 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 be processed in NCTracks prior to submitting a claim for 2nd 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
• Pharmacies may administer Pfizer COVID-19 Vaccine to any Medicaid and NC Health Choice beneficiary 16 years and older.  Pharmacies may administer Moderna COVID-19 Vaccines to any Medicaid and NC Health Choice beneficiary 18 years and older.  All other vaccines (non-COVID-19 vaccines), that are approved by the NC Board of Pharmacy to be administered by a pharmacist, are only permissible to be administered at a pharmacy for Medicaid beneficiaries 19 years and older. 
• TJ modifier should be appended to all NC Health Choice claims (age 16 through 18 years)
• EP modifier should be appended to all non-NC Health Choice (only Medicaid beneficiaries) younger than 21 years of age
• CG modifier should be appended to ALL COVID-19 vaccine AND administration claims submitted by a pharmacy participating in the immunization program
  • EXCEPTION - CVS/Walgreens pharmacies participating in the Long-Term Care (LTC) immunization program for beneficiaries residing at the participating LTC

COVID-19 Vaccine Billing Codes for Medicaid Beneficiaries

Vaccine CPT Codes to Report

Administrative CPT Codes to Bill

CONTACT

NCTracks Call Center: (800) 688-6696