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

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

Administrative CPT Codes for ALL COVID-19 Vaccines to Bill

Contact

NCTracks Contact Center: 800-688-6696