SPECIAL BULLETIN COVID-19 #160: Janssen COVID-19 Vaccine HCPCS Code 91303 and 0031A Billing Guidelines

Janssen 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 18 years of age and older. Effective with date of service Feb. 27, 2021, the North Carolina Medicaid and NC Health Choice programs cover Janssen COVID-19 Vaccine (N/A) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 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, 5x10^10 viral particles/0.5mL dosage, for intramuscular use.

Janssen COVID-19 Vaccine is a preservative-free suspension for injection in a multiple dose vial. It is administered intramuscularly as a single dose (0.5 mL). See full prescribing information for further detail.

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(s) required for billing is/are:  Z23 - Encounter for immunization
• Providers must bill with HCPCS code: 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, 5x10^10 viral particles/0.5mL dosage, for intramuscular use
• One Medicaid and NC Health Choice unit of coverage is: 0.5 mL (1 dose)
• The maximum reimbursement rate per unit is: N/A (federally supplied)
• Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is/are: 59676-0580-05, 59676-0580-15
• 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:

• Providers must bill with HCPCS code: 0031A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative-free, 5x1010 viral particles/0.5mL dosage, single dose
• Medicaid and NC Health Choice will reimburse at the Medicare approved COVID-19 vaccination administration rate of $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.
• 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 Janssen 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 (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.

COVID-19 Vaccine Billing Codes for Medicaid Beneficiaries

Vaccine CPT Codes for ALL Covid-19 Vaccines to Report

Administrative CPT Codes for ALL Covid-19 Vaccines to Bill

Contact

NCTracks Contact Center: 800-688-6696