Moderna COVID-19 Vaccine, Bivalent Booster Dose (6 Months through 5 Years) HCPCS Code 91316: Billing Guidelines

Effective Dec. 8, 2022

Effective with date of service Dec. 8, 2022, the Medicaid and NC Health Choice programs cover Moderna COVID-19 Vaccine, Bivalent (Original and Omicron BA.4/BA.5) - Booster Dose (6 months through 5 years) (N/A) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 91316 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 10 mcg/0.2 mL dosage, for intramuscular use.

The U.S. Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) to permit the emergency use of the unapproved product, Moderna COVID-19 Vaccine, Bivalent (Original and Omicron BA.4/BA.5), for active immunization to prevent COVID-19 in individuals 6 months of age through 5 years of age. A single booster dose (0.2 mL) of Moderna COVID-19 Vaccine, Bivalent may be administered at least two months after completion of primary vaccination with Moderna COVID-19 Vaccine. See full prescribing information for further detail.

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 HCPCS code: 91316 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 10 mcg/0.2 mL dosage, for intramuscular use
  • Providers must bill with administration code: 0164A - Moderna Covid-19 Bivalent Vaccine (Dark Pink Cap) 10MCG/0.2ML Administration - Booster
  • One Medicaid and NC Health Choice unit of coverage is: 10 mcg (1 dose) 
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is/are: 80777-0283-02, 80777-0283-99

Important Claims Information

  • Medicaid and NC Health Choice will reimburse at the Medicare-approved COVID-19 vaccination administration rate at $65
  • Claims must contain both administration codes and vaccine codes to pay, and NDC that corresponds to the vaccine administered
  • 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 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 aged 19 and older. 
  • EP modifier should be appended to all non-NC Health Choice (only Medicaid beneficiaries) younger than age 21
  • TJ modifier should be appended to all NC Health Choice vaccine claims
  • CG modifier should be appended to ALL COVID-19 vaccine AND administration claims submitted by a pharmacy participating in the immunization program

Contact

NCTracks Call Center: 800-688-6696

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