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How COVID-19 vaccine will affect medical coding and medical billing [Here’s what you need to know]

Posted By Kara Carlisle, RHIA

Hello! I hope everyone is having a safe Holiday Season! 

This current blog will stick with the big topic of 2020, we have discussed Covid-19 coding and billing many, many times in 2020, but with the rapidly progressing research, Covid-19 education is ever advancing.  We will be discussing the newly approved Covid-19 vaccine with regards to coding and billing. 

Below is a grid obtained from the CMS.gov website with the CPT codes along with the payment allowances, as of the writing of this blog (12/14/2020) the effective dates have not been updated. As of now Medicare will cover the cost of the Covid-19 vaccine as well as the administration and will waive the out-of-pocket costs. Medicare will pay $16.95 for the first dose of the vaccine and $28.39 for the for the second dose of the vaccine.

Payment Allowances and Effective Dates for COVID-19 Vaccines and their Administration during the Public Health Emergency:

 

Code

CPT Short Descriptor

Labeler Name

Vaccine/Procedure Name

Payment Allowance

Effective Dates

91300

SARSCOV2 VAC 30MCG/0.3ML IM

Pfizer

Pfizer-Biontech Covid-19 Vaccine

$0.010*

xx/xx/xxxx – TBD

0001A

ADM SARSCOV2 30MCG/0.3ML 1ST

Pfizer

Pfizer-Biontech Covid-19 Vaccine Administration – First Dose

$16.940**

xx/xx/xxxx – TBD

0002A

ADM SARSCOV2 30MCG/0.3ML 2ND

Pfizer

Pfizer-Biontech Covid-19 Vaccine Administration – Second Dose

$28.390**

xx/xx/xxxx – TBD

91301

SARSCOV2 VAC 100MCG/0.5ML IM

Moderna

Moderna Covid-19 Vaccine

$0.010*

xx/xx/xxxx – TBD

0011A

ADM SARSCOV2 100MCG/0.5ML1ST

Moderna

Moderna Covid-19 Vaccine Administration – First Dose

$16.940**

xx/xx/xxxx – TBD

0012A

ADM SARSCOV2 100MCG/0.5ML2ND

Moderna

Moderna Covid-19 Vaccine Administration – Second Dose

 $28.390**

xx/xx/xxxx – TBD

* Since we anticipate that providers, initially, will not incur a cost for the product, CMS will update the payment allowance at a later date.  Providers should not bill for the product if they received it for free.

** These rates will also be geographically adjusted for many providers.  Certain settings utilize other payment methodologies, such as payment based on reasonable costs.

Also, to mention, we have coding and payment allowances for Monoclonal Antibodies. According to FDA.gov: 

Monoclonal antibodies are laboratory-made proteins that mimic the immune system’s ability to fight off harmful antigens such as viruses. Bamlanivimab is a monoclonal antibody that is specifically directed against the spike protein of SARS-CoV-2, designed to block the virus’ attachment and entry into human cells. Nov 9, 2020

Code

CPT Short Descriptor

Labeler Name

Vaccine/Procedure Name

Payment Allowance

Effective Dates

Q0239

bamlanivimab-xxxx

Eli Lilly

Injection, bamlanivimab, 700 mg

 $0.010*

11/10/2020 – TBD

M0239

 

bamlanivimab-xxxx infusion

Eli Lilly

Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring

$309.600***

11/10/2020 – TBD

Q0243

casirivimab and imdevimab

Regeneron

Injection, casirivimab and imdevimab, 2400 mg

$0.010*

11/21/2020 – TBD

M0243

casirivi and imdevi infusion

Regeneron

intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring

$309.600***

11/21/2020 – TBD

 

Payment Allowances and Effective Dates for COVID-19 Monoclonal Antibodies and their Administration during the Public Health Emergency:

* Since we anticipate that providers, initially, will not incur a cost for the product, CMS will update the payment allowance at a later date.  Providers should not bill for the product if they received it for free.

*** Medicare will pay a rate of $309.60 for many providers. These rates will also be geographically adjusted for many providers.  Certain settings utilize other payment methodologies, such as payment based on reasonable costs.

Here are a few more elements to consider when coding the vaccines:

AAFP provides the following guidance for coding an E&M service during the same encounter as the vaccine:

If you administer the vaccine during a significant, separately identifiable evaluation and management (E/M) service, such as an office visit, and you document the work of that E/M service, you may report an E/M code in addition to the codes for the vaccine (if applicable) and its administration. Be sure to append modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) to the E/M code in this situation. The usual cost-sharing will apply to the E/M service in this case.

As an additional note, you may want to consider adding CPT 99072 to report additional expenses incurred during the COVID 19 Public Health Emergency (PHE), this code became effective September 8, 2020.  

 (Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease.) 

  • Only billable for face-to-face services in a non-facility place of service setting, “and in an area where it is required to mitigate the transmission of the respiratory disease for which the PHE was declared”. 
  • May be reported once per in-person patient encounter, per provider. 
  • Only to be reported during the PHE; once the PHE has ended the code is no longer valid. 
  • Not billable when the physician or other qualified health care professional performs the clinical staff activities noted by the AMA. 
  • Not separately billable by home health specialties or in the clinic setting. 
  • It is a good idea to check with your payer to determine guidelines for 99072. 

 

References:

Tags: Medical Coding, RCM, healthcare revenue cycle support, medical coding experts, COVID-19