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SPECIAL BULLETIN COVID-19 #196: Pfizer Pediatric Vaccine Authorized Effective Oct. 29, 2021, Medicaid & NC Health Choice cover Pfizer Pediatric Vaccine

November 4, 2021
This bulletin was updated on Jan. 26, 2022, to correct one NDC for Medicaid and NC Health Choice Billing. 
PFIZER Pediatric COVID-19 Vaccine HCPCS code 91307: Billing Guidelines

Pfizer Pediatric 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 five years and older. Effective with date of service Oct. 29, 2021, the Medicaid and NC Health Choice programs cover Pfizer Pediatric COVID-19 Vaccine for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 91307 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use.

Pfizer Pediatric COVID-19 vaccine is a preservative-free suspension for injection in a multiple dose vial. It is administered intramuscularly as a single dose (0.2 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.. 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 CPT code: 91307 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use
  • One Medicaid and NC Health Choice unit of coverage is: 0.2 mL (one dose)
  • The maximum reimbursement rate per unit is: N/A (federally supplied)
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 59267-1055-01, 59267-1055-02, 59267-1055-04
  • 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 $40. 
  • 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 (e.g., 0071A or 0072A for corresponding administration code for first and second pediatric vaccine, respectively)
  • 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 Pfizer PEDIATRIC COVID-19 Vaccines to any Medicaid beneficiary (five through 11 years of age) and NC Health Choice beneficiary (six through 11 years of age) {in general, during the pandemic, pharmacies have been given authorization to administer any COVID-19 vaccine as per FDA/EUA age approval to Medicaid and/or NC Health Choice beneficiary}. 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

Vaccine CPT Code to Report

NDC

CPT Code Description

91307

59267105501,

59267105502,

59267105504

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use

Administrative CPT Codes for ALL COVID-19 Vaccines to Bill

Administration CPT Code(s) to Bill

CPT Code Description

0071A

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, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose

0072A

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, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; second dose

Contact

NCTracks Contact Center: 800-688-6696

 

 

 

 

 

 

This blog is related to:

  • Bulletins
  • All Providers
  • COVID-19

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https://medicaid.ncdhhs.gov/blog/2021/11/04/special-bulletin-covid-19-196-pfizer-pediatric-vaccine-authorized