Pfizer-BioNTech COVID-19 Vaccine, Bivalent 6 Months through 4 Years HCPCS Code 91317: Billing Guidelines

Effective Dec. 8, 2022

Effective with date of service Dec. 8, 2022, the NC Medicaid and NC Health Choice programs cover Pfizer-BioNTech COVID-19 Vaccine, Bivalent (Original and Omicron BA.4/BA.5) - 6 months through 4 years (N/A) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 91317 - Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use.

Pfizer-BioNTech COVID-19 Vaccine, Bivalent is authorized for use in individuals 6 months through 4 years of age as the third dose in the 3-dose primary series. A single dose (0.2 mL) of Pfizer-BioNTech COVID-19 Vaccine, Bivalent may be administered at least eight weeks after Dose 2 (Pfizer-BioNTech 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: 91317 - Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use.
  • Providers must bill with administration HCPCS code 0173A - Pfizer-BioNTech Covid-19 Pediatric Vaccine, Bivalent (Maroon Cap) Administration -Third Dose
  • One Medicaid and NC Health Choice unit of coverage is: 0.2 mL (3 mcg) 
  • Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is/are: 59267-0609-01, 59267-0609-02

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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