SPECIAL BULLETIN COVID-19 #186: Booster Dose of Pfizer-BioNTech COVID-19 Vaccine CDC Recommendations and Medicaid and NC Health Choice Billing

On Sept. 24, 2021, the Centers for Disease Control and Prevention (CDC) recommended:

• people 65 years and older and residents in long-term care settings should receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series, 
• people aged 50–64 years with underlying medical conditions should receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series, 
• people aged 18–49 years with underlying medical conditions may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series, based on their individual benefits and risks, and 
• people aged 18-64 years who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series, based on their individual benefits and risks. 

More information on the CDC’s recommendations can be found here.  More information on the FDA’s authorization can be found here.

The Pfizer-BioNTech vaccine booster dose is approved for people 18 years and older and is different from the FDA approved third dose of the Pfizer vaccine which is approved for the immunocompromised population.

The recommendations for the booster shot vaccine only applies to people who previously received a Pfizer-BioNTech primary series (i.e., the first two doses of a COVID-19 vaccine). Medicaid beneficiaries should talk to their healthcare provider about whether getting a Pfizer-BioNTech COVID-19 booster shot is appropriate for them.

Beginning Sept. 24, 2021, NC Medicaid vaccine providers may begin administering the booster dose of mRNA COVID-19 vaccine to those beneficiaries who qualify and by self-attestation.

Payment amount will be equivalent as for other doses of the COVID-19 vaccine at $40.00 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
• 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 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

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
   

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