SPECIAL BULLETIN COVID-19 #170: Update on Vaccination Counseling Code Reimbursement
This bulletin was updated on Sept. 24, 2021 by SPECIAL BULLETIN COVID-19 #184: Update on Vaccination Counseling Code Reimbursement
Addendum to COVID-19 Bulletin #168
The addendum was updated to include information regarding guidance on billing and coding criteria, guidance for parents, counseling methods, reimbursement ranges and the time frame during which the code is valid.
NC Medicaid recognizes the importance of vaccinating Medicaid beneficiaries for COVID-19. We also understand the additional administrative responsibilities this places on Medicaid providers due to providing the vaccine in your offices and the additional time it takes for counseling and informed consent, as well as post-vaccine observation. NC Medicaid reimburses for the provision of the vaccine at the same rate as Medicare and is creating an additional payment to encourage access to vaccines during the Public Health Emergency (PHE).
Effective June 22, 2021, CPT 99401: Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual, up to 15 minutes has been added to counsel Medicaid beneficiaries regarding the benefits of receiving the COVID-19 vaccine.
CPT 99401 can be billed at only one visit for each beneficiary per day, but there are not quantity limits for the number of times this education can be provided to an individual beneficiary. Counseling may be provided in person, via live audio/video (telehealth) or telephonically. Additionally, this service can be billed by multiple providers and can be billed multiple times on different days.
Providers must bill CPT 99401 with a CR modifier to indicate a PHE code. There is no requirement for a specific diagnosis code. The following coding criteria will apply:
- Requires 25 modifier if in addition to OV E&M, if applicable
- Requires CR and GT modifiers if provided via telehealth
- Requires CR and KX modifiers if provided telephonically
Providers are encouraged to counsel Medicaid beneficiaries of any age. Parents can be counseled about giving the vaccine to their children age 12 and over. Parents or guardians of Medicaid children can be counseled on the benefit of receiving the COVID-19 vaccination even if the parent or guardian is not enrolled in NC Medicaid. The counseling session for the parent or guardian can be billed to the child’s Medicaid ID, but only one code can be billed per day.
This service can only be provided by MD/DO, NP, PA, CNM and, if provided at LHD, FQHC or RHC by one of these professionals, will be reimbursed outside of the PPS rate. Reimbursement is relative value units (RVU) based and ranges from $20.68 – $24.54 for Facility and from $32.28 – $38.30 for Non-Facility. This coverage is time-limited, initially for three months to end on Sept. 22, 2021, and will be reevaluated throughout the PHE. For more information on the rates, please refer to the applicable Fee Schedule listed below.
- Physician Services
- Nurse Practitioner
- Nurse Midwife
- Physicians Services E&M
- Physician Assistant E&M
- Nurse Practitioner E&M
NCTracks Contact Center: 800-688-6696