COVID-19 Vaccine and Reimbursement Guidelines for 2023-2024 for NC Medicaid

Note: This bulletin replaces NC Medicaid COVID-19 Vaccine and Reimbursement Guidelines for 2023-2024 published on Oct. 2, 2023.

The following information has been updated in this version of the bulletin and are applicable to NC Medicaid Direct and NC Medicaid Managed Care:

• Based on updated Centers for Medicare and Medicaid (CMS) guidance related to the PREP Act, NC Medicaid will begin covering pharmacy point of sale claims for Covid-19 vaccines for beneficiaries ages 3 years and up through Dec. 31, 2024, with an effective date of Sept. 11, 2023.
• Addition of Novavax COVID-19 vaccines for 2023-2024 season (adjuvanted suspension for injection, for intramuscular use (2023-2024 Formula), effective Oct. 3, 2023, and removal of previously approved Novavax vaccines, effective Oct. 2, 2023. Novavax was additionally added to the Vaccines for Children (VFC) program.
• Addition of two new Comirnaty® NDCs, effective Nov. 13, 2023. 

On Sept. 11, 2023, the Food and Drug Administration (FDA), approved new COVID-19 vaccines for the 2023-2024 season: FDA: Covid-19 Vaccines. On Sept. 12, 2023, the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) recommends 2023–2024 (monovalent, XBB containing) COVID-19 vaccines as authorized under Emergency Use Authorization (EUA) or approved by BLA in persons ≥6 months of age. This will be published in Morbidity and Mortality Weekly Report (MMWR) in the coming months at CDC COVID-19 ACIP Vaccine Recommendations.

The new COVID-19 vaccines are available through commercial pathways as outlined in the U.S. Department of Health and Human Services: COVID-19 Commercialization transition information. NC Medicaid will cover the new COVID-19 vaccines and CPT codes 91318-91322 with an effective date of Sept. 11, 2023.  

• The new COVID-19 vaccines are part of the VFC program (CDC VFC List) for beneficiaries <19 years old.  
• Additionally, based on updated CMS guidance related to the PREP Act, NC Medicaid will begin covering pharmacy point of sale claims for COVID-19 vaccines for beneficiaries ages 3 years and up through Dec. 31, 2024, with an effective date of Sept. 11, 2023.  

Coverage ended for the previously approved Novavax vaccines under 91304 on Oct. 2, 2023. The Novavax vaccines for the 2023-24 season under code 91304 are covered with an effective date of Oct. 3, 2023. The Novavax 2023-24 vaccine is part of the VFC program.   

COVID-19 Vaccines Reimbursement

NC Medicaid will reimburse at the Medicare-approved COVID-19 vaccination administration rate of $65 until Sept. 30, 2024. Effective Oct. 1, 2024, reimbursement for COVID-19 vaccine administration will align with the standard administration rate per COVID-19 vaccine dose. 

For Medicaid Billing:

• The ICD-10-CM diagnosis code(s) required for billing is/are: Z23 - Encounter for immunization.
• Providers must bill with the correct HCPCS codes for the COVID-19 vaccine administered.
• Providers shall bill their usual and customary charge for non-340B drugs.
• PADP reimburses for drugs billed for Medicaid beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is their actual acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the "UD" modifier on the drug detail.
• The fee schedule for the PADP is available on the NC Medicaid Fee Schedule & Covered Code portal.  
• The maximum reimbursement rate per unit is: Wholesale Acquisition Cost (WAC) +3% and is NDC specific.
• NC Medicaid will continue to cover COVID Counseling for members who are under age 21 until Sept. 30, 2024, per guidance from the Centers for Medicare & Medicaid Services (CMS) and consistent with EPSDT.
• 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.
• Copays may not be charged for COVID-19 immunization or administrations.
• COVID-19 vaccines are now part of the Vaccines for Children Program for beneficiaries < 19 years of age. Pharmacies can now only administer for beneficiaries >19 years of age.
• EP modifier should be appended for all NC Medicaid beneficiaries younger than age 21.
• 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 Counseling Coverage

This remains the same as in SPECIAL BULLETIN COVID-19 #268: COVID-19 Testing, Vaccination and Counseling Coverage After the Federal Public Health Emergency.

NC Medicaid recognizes the importance of vaccinating Medicaid beneficiaries against COVID-19. NC Medicaid continues to encourage providers to work with their patients to receive COVID-19 vaccines.

The coverage for COVID-19 Vaccine Counseling (CPT 99401) for adults 21 and older ended with the end of the federal PHE on May 11, 2023.

NC Medicaid will continue to cover COVID-19 Counseling for members who are under age 21 until Sept. 30, 2024, per guidance from CMS and consistent with EPSDT.

NC Medicaid understands the additional administrative responsibilities COVID-19 places on Medicaid providers due to providing the vaccine in your offices and the additional time it takes for counseling and informed consent, as well as post-vaccine observation. NC Medicaid is pleased to continue to offer vaccine counseling for members under age 21 until Sept. 30. 2024, to encourage access to COVID-19 vaccines for children.

For COVID-19 vaccine counseling, providers should continue to leverage CPT 99401 when counseling members under age 21.

CPT 99401: Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual, up to 15 minutes has been added to counsel Medicaid beneficiaries regarding the benefits of receiving the COVID-19 vaccine.  

Note: COVID-19 Counseling is available for all NC Medicaid beneficiaries under age 21, both Medicaid Direct and Medicaid Managed Care.

CPT 99401 can be billed at only one visit for each beneficiary per day, but there are no quantity limits for the number of times this education can be provided to an individual beneficiary. Counseling may be provided in person, through live audio/video (telehealth) or telephonically. Additionally, this service can be billed by multiple providers and can be billed multiple times on different days.

There is no requirement for a specific diagnosis code. The following coding criteria will apply:

• Requires 25 modifier if in addition to OV E&M, if applicable.
• Requires GT modifiers if provided via telehealth.
• Requires KX modifiers if provided telephonically.

Providers are encouraged to counsel Medicaid beneficiaries of any age, but providers will only be reimbursed for counseling members under age 21. Parents can be counseled about giving the vaccine to their children age 6 months and over. Parents or guardians of Medicaid children can be counseled on the benefit of receiving the COVID-19 vaccination even if the parent or guardian is not enrolled in NC Medicaid. The counseling session for the parent or guardian can be billed to the child’s Medicaid ID, but only one code can be billed per day.

The service can only be provided by MD/DO, NP, PA, CNM and, if provided at LHD, FQHC or RHC by one of these professionals, will be reimbursed outside of the PPS rate. The coverage is time-limited and will end on Sept. 30, 2024, for NC Medicaid beneficiaries under age 21 (Medicaid Direct and NC Medicaid Managed Care).

NC Immunization Program/Vaccines for Children (NCIP/VFC)

Under NC Immunization Program/Vaccines for Children (NCIP/VFC) guidelines, the NC Division of Public Health (DPH) Immunization Branch distributes all childhood vaccines that are recommended by the Advisory Committee on Immunization Practices (ACIP) to local health departments, Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), hospitals and private providers.

For the 2023-2024 COVID-19 season, NCIP/VFC COVID-19 vaccines are available at no charge to providers for children 6 months through 18 years of age who are eligible for the VFC program, according to the NCIP coverage criteria. The current NCIP coverage criteria and definitions of VFC categories can be found on DPH’s Immunization Branch web page.

For providers interested in enrolling in the VFC program, information can be found on the CDC information page and the NC DPH website.  

Eligible VFC children include ALL Medicaid beneficiaries (through 18 years of age).

For VFC/NCIP vaccines administered to VFC-eligible children, providers must report only the vaccine code(s) with $0.00. Providers may bill NC Medicaid for the administration fee for Medicaid.

Providers who administer privately purchased vaccines to VFC eligible beneficiaries will NOT be reimbursed for the vaccine and cannot bill the beneficiary for that cost. Only the administration fee(s) will be reimbursed.  

An exception is made for COVID-19 vaccines. If a VFC eligible beneficiary received a non-VFC-provided COVID-19 dose from a pharmacy provider that is authorized to administer the vaccine under the HHS COVID-19 PREP Act declaration, NC Medicaid will reimburse the vaccine through Dec. 31, 2024, with an effective date of Sept. 11, 2023.  

Providers must purchase vaccines for beneficiaries who are not VFC-eligible. For Medicaid-eligible beneficiaries aged 19 years and older, purchased vaccine and administration costs may be billed to NC Medicaid, according to the guidelines stated in Tables 2 and 3 below. To determine who is eligible for NCIP COVID-19 and other vaccines, visit DPH’s Immunization Branch web page. 

Billing/Reporting COVID-19 Vaccines for Medicaid Beneficiaries

The following tables indicate the vaccine codes that may be either reported (with $0.00 billed) or billed (with the usual and customary charge) for the COVID-19 vaccine, depending on the age of the beneficiaries and the formulation of the vaccine. The tables also indicate the administration codes that may be billed, depending on the age of the beneficiaries and the vaccine(s) administered to them.

Note: Specific information on billing all immunization administration codes for Health Check beneficiaries can be found in the Health Check Program Guide available at NCTracks Provider Policies, Manuals, Guidelines, and Forms.

If you have any questions or need assistance, please contact the Immunization Branch Help Desk at 877-873-6247 and press option 6.

Table 1
COVID-19 Billing Codes for Medicaid Beneficiaries Less Than 19 Years of Age Who Receive VFC COVID-19 Vaccine. These codes are reported with $0.00.

*NDCs listed on Table 1 are NDCs of packs of vials as distributed by the Department to Public Health. For claims processing, providers should use the NDC listed on the actual vial used for administration as listed at the bottom of this bulletin.

Administrative CPT Codes to Bill
90480EP - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, single dose 
 

Table 2
COVID-19 Billing Codes for Medicaid Beneficiaries 19 to 21 Years of Age

Use the following codes to bill Medicaid for a COVID-19 vaccine purchased and administered to beneficiaries aged 19-21 years.

Note: The VFC/NCIP provides COVID-19 products for recipients aged 6 months through 18 years only. The VFC/NCIP will NOT provide COVID-19 vaccine for recipients 19 years and older. 

Administrative CPT Codes to Report
90480EP - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, single dose

Table 3
COVID-19 Billing Codes for Medicaid Beneficiaries 21 Years of Age and Older

Use the following codes to bill Medicaid for COVID-19 vaccine purchased and administered to beneficiaries 21 years of age and older.

Note: The VFC/NCIP provided COVID-19 products for VFC-age (6 months through 18 years of age) beneficiaries only. The VFC/NCIP will not provide COVID-19 vaccine for beneficiaries 19 years and older.

Administrative CPT Code(s) to Bill
90480 - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, single dose

Immunization Billing for Medicaid from FQHCs and RHCs

For beneficiaries 0 through 20 years of age

• If vaccines are provided through the NCIP/VFC, the center/clinic shall report the CPT vaccine codes (with $0.00 billed) under Physician Services NPI and may bill for the administration codes (CPT procedure codes 90480EP). This billing is appropriate when only vaccines are provided at the visit, or if vaccines were provided in conjunction with a wellness check. If a core visit was billed, CPT vaccine codes shall be reported (with $0.00 billed) under Physician Services NPI and an administration code shall not be billed.
• If purchased vaccines (non-VFC eligible) were administered, the center/clinic may bill the CPT vaccine codes (with their usual and customary charge) under the Physician Services NPI for the vaccines administered and may bill for the administration codes (with the usual and customary charge). This billing is appropriate if only vaccines were given at the visit or if vaccines were given in conjunction with a wellness check. If a core visit was billed, CPT vaccine codes shall be reported (with $0.00 billed) under the Physician Services NPI provider number and the administration codes shall not be billed. For detailed billing guidance, refer to the Health Check Program Guide available at NCTracks Provider Policies, Manuals, Guidelines, and Forms.

For beneficiaries 21 years of age and older

• When purchased vaccines are administered, CPT vaccine codes may be billed (with the usual and customary charge) and administration codes may be billed (with the usual and customary charge) under the Physician Services NPI. This is applicable when vaccine administration was the only service provided that visit. When a core visit is billed, the CPT vaccine code shall be reported (with $0.00 billed) under the Physician Services NPI and an immunization administration code may not be billed.
• For COVID-19 vaccine and administration fee rates, refer to the DHB's Physician Administered Drug Program (PADP) and Physician Services Fee Schedule.

Immunization Billing for Medicaid Beneficiaries from Immunizing Pharmacies

For beneficiaries 19 years of age and older

Effective Jan. 1, 2016, NC Medicaid will reimburse pharmacies for covered vaccines, including COVID-19 vaccines, as permitted by G.S. 90-85.15B (see below) when administered to NC Medicaid beneficiaries 19 years of age and older by an immunizing pharmacist.

Pharmacies will be allowed to bill NC Medicaid Direct for vaccines on pharmacy claims at point of sale. Immunizing pharmacists are not required to submit vaccine administration claims on medical 837P or CMS 1500 form, but this will remain an option for immunizing pharmacists who wish to do so. Additional information can be found in the Vaccine Immunization Claims Can Be Submitted on Pharmacy Claims for NC Medicaid Direct Beneficiaries published on Nov. 28, 2022.

Based on updated CMS guidance related to the PREP Act, NC Medicaid will begin covering pharmacy point of sale claims for COVID-19 vaccines for beneficiaries ages 3 years and up through Dec. 31, 2024, with an effective date of Sept. 11, 2023.

Table 4
NDC codes for the 2023-2024 COVID-19 Vaccine Products
 

Table 5
Billing Codes to be used by Pharmacist for Medicaid Beneficiaries 19 Years of Age or Older via CMS 1500 or 837P Claims

*The CG modifier must be appended to every vaccine and vaccine administration CPT code used to bill vaccines by pharmacists. The CG modifier identifies a Pharmacy Provider in NCTracks for vaccine claims billing purposes.  

Billing Codes to be used by Pharmacists for NC Medicaid Beneficiaries 19 Years of Age and Older via CMS 1500 or 837P Claims

90480CG - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, single dose

The CG modifier must be appended to every vaccine and vaccine administration CPT code used to bill vaccines by pharmacists. The CG modifier identifies a Pharmacy Provider in NCTracks for vaccine claims billing purposes.  

Detailed information about the regulations regarding pharmacist immunization can be found at Pharmacist Administrated Vaccine and Reimbursement Guidelines published in the October 2016 Medicaid Bulletin. Please note that NDCs are required on vaccine claims.

NDC's Change Each Year for COVID-19 Vaccines

Providers are required to use appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code. Note that not all products and NDCs under their respective CPT codes will be covered.  

COVID-19 vaccines are licensed each year with new NDCs, so it is important to report the correct code for the products you are using to avoid having claims deny with edit 00996 (Mismatched NDC) which will require the claim to be resubmitted with the correct NDC. Below are the COVID-19 vaccine procedure (CPT) codes and corresponding NDCs that should be used for the 2023-2024 COVID-19 season:

CPT and NDC codes for the 2023-2024 COVID-19 Vaccine Products for Pharmacies

Contact

GDIT: 800-688-6696