SPECIAL BULLETIN COVID-19 #176: Third Dose of COVID-19 Vaccine Available

Applies to beneficiaries meeting specific criteria

On August 12, 2021, the FDA modified the Emergency Use Authorizations (EUAs) for Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine to allow for administration of an additional dose (e.g., a third dose) of an mRNA COVID-19 vaccine after an initial two-dose primary mRNA COVID-19 vaccine series for certain immunocompromised people (e.g., people who have undergone solid organ transplantation or have been diagnosed with conditions that are considered to have an equivalent level of immunocompromise). The age groups authorized to receive the additional dose are unchanged from those authorized to receive the primary vaccination series:

• Pfizer-BioNTech: ages ≥12 years
• Moderna: ages ≥18 years

The authorizations for these vaccines have been amended to allow for an additional, or third, dose to be administered at least 28 days following the two-dose regimen of the same vaccine to individuals who have undergone solid organ transplantation, or who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise. More information can be found here.

NC Medicaid vaccine providers may begin administering an additional dose of mRNA COVID-19 vaccine to people with moderate to severely compromised immune systems after an initial two-dose vaccine series.

The additional mRNA COVID-19 vaccine dose should be the same vaccine product as the initial 2-dose mRNA COVID-19 primary vaccine series (Pfizer-BioNTech or Moderna). If the mRNA COVID-19 vaccine product given for the first two doses is not available, the other mRNA COVID-19 vaccine product may be administered. A person should not receive more than three mRNA COVID-19 vaccine doses.

Conditions and treatments associated with moderate and severe immune compromise include but are not limited to:

• Active treatment for solid-tumor and hematologic malignancies
• Receipt of solid-organ transplant and taking immunosuppressive therapy
• Receipt of CAR-T-cell or hematopoietic stem cell transplant (within two years of transplantation or taking immunosuppression therapy)
• Moderate or severe primary immunodeficiency (e.g., DiGeorge syndrome, Wiskott-Aldrich syndrome)
• Advanced or untreated HIV infection
• Active treatment with high-dose corticosteroids (i.e., ≥20mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor-necrosis (TNF) blockers and other biologic agents that are immunosuppressive or immunomodulatory.

Patient may self-attest to their medical condition. An updated Standing Order is forthcoming.

According to an American Medical Association press release, the vaccine administration CPT code and long descriptor assigned to the third dose:

• Pfizer COVID-19 vaccine - 0003A - 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/0.3 mL dosage, diluent reconstituted; third dose
• Moderna COVID -19 vaccine – 0013A - 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, 100 mcg/0.5 mL dosage; third dose

NC Medicaid will pay for administering an additional dose of COVID-19 vaccine consistent with the FDA emergency use authorization (EUA). Payment amount will be equivalent as for other doses of the COVID-19 vaccine at $40 each.

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
• The maximum reimbursement rate per unit is: N/A (only administration charge will be reimbursed).
• Claims must have appropriate NDCs, which 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.
• 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.

COVID-19 Vaccine Billing Codes for Medicaid Beneficiaries

Vaccine CPT Codes to Report

Currently, there are insufficient data to support the use of an additional mRNA COVID-19 vaccine dose after a single-dose Janssen COVID-19 vaccination series in immunocompromised people. FDA and CDC are actively working to provide guidance on this issue.

Please see the updated Interim Clinical Considerations for use of COVID-19 Vaccines Currently Authorized in the United States for more details.

Other resources and links:

• Pfizer EUA
• Pfizer Health Care Provider Fact Sheet
• Pfizer Fact Sheet for Recipients
• Moderna EUA
• Moderna Health Care Provider Fact Sheet
• Moderna Fact Sheet for Recipients

CONTACT 

NCTracks Call Center: 800-688-6696