This article will assist you with proper billing relating to COVID-19 vaccine and monoclonal antibody (mAb) infusion. Beneficiary coinsurance and deductible will be waived.
To bill single claims for COVID-19 vaccines and mAb infusions, follow the instructions below.
Effective for dates of services on and after January 1, 2022, COVID-19 vaccines and mAbs provided to patients enrolled in a Medicare Advantage plan are to be billed to the Medicare Advantage plan.
For coding, effective dates and payment allowances for COVID-19 vaccines, refer to the CMS vaccine pricing - COVID-19 vaccines and monoclonal antibodies
The types of bill to report for the COVID-19 vaccine and mAb infusion on the Part A claim form, or electronic equivalent, are:
Inpatient Part B
Hospital - 12X
SNF - 22X
Outpatient
Hospital - 13X
SNF - 23X
End stage renal disease - 72X
Comprehensive outpatient rehabilitation facility - 75X
Critical access hospital - 85X
The revenue codes for reporting the COVID-19 vaccine and mAb infusion are:
0771 preventive care services, vaccine administration.
0636 pharmacy, drugs requiring detailed coding.
For information on dosing intervals, refer to the CDC article Vaccine and Immunizations.
HCPCS M0201(administration of pneumococcal, influenza, hepatitis b, and/or covid-19 vaccine inside a patient's home) is billable only on the following TOBs: 13X, 34X, 72X, 75X, 81X, 82X, and 85X.
For additional billing information on M0201, review the following CMS resources:
Billing example for first dose:
Condition code:
A6 - 100% payment.
Diagnosis code:
Z23 - Encounter for immunization.
Required as primary diagnosis.
Note: For vaccines provided for inpatients, use the date of discharge or date Part A benefits exhausted as the date of service.
For payment allowances and coding refer to the CMS vaccine pricing - COVID-19 vaccines and monoclonal antibodies and the CMS COVID-19 Monoclonal Antibodies webpages.
Diagnosis code:
Use appropriate diagnosis coded to highest level of specificity
U071 - use as appropriate.
Note: For mAb provided for inpatients, use the date of discharge or date Part A benefits exhausted as the date of service.
For billing guidance for Indian Health Services, Tribal and Urban Indians please refer to the Indian Health Services COVID-19 vaccine and monoclonal antibody (mAb) infusion administration article.
COVID-19 vaccines and their administration will be paid the same way influenza and pneumococcal vaccines and their administration are paid in FQHCs. Influenza and pneumococcal vaccines and their administration are paid at 100 percent of reasonable cost through the cost report. For a face-to-face encounter with administration on same day, the FQHC should bill for the cost of the COVID-19 or mAb administration to the encounter charge on the bill; reporting of these codes is informational only and reimbursement is made at the time of cost settlement. When COVID-19 vaccine and mAb doses are provided by the government without charge, only bill the vaccine administration, do not include the vaccine on the claim when the vaccines are free (do not show a 0.00 on claim).
Independent and provider-based RHCs do not include charges for vaccine or administration for COVID-19 or mAb on a claim, reimbursement is made at the time of cost settlement. Claims will process with $0 payment when submitted with only the vaccine and/or administration.
COVID-19 vaccines and their administration will be paid the same way influenza and pneumococcal vaccines and their administration are paid in RHCs. Influenza and pneumococcal vaccines and their administration are paid at 100 percent of reasonable cost through the cost report.
For patients in a Part A-covered SNF stay, CMS exercised “enforcement discretion,” which allowed Medicare-enrolled immunizers, including but not limited to pharmacies working with the United States, to bill directly and receive direct payment from the Medicare program for vaccinating Medicare SNF residents.
The enforcement discretion associated with vaccinating Medicare SNF residents ended on June 30, 2023, meaning that immunizers are no longer be able to bill Medicare directly for vaccines furnished to patients for a Medicare Part A-covered SNF stay. Beginning on July 1 ,2023, typical SNF consolidated billing regulations are in place, which require SNFs to bill for all services furnished to patients in a Medicare-covered SNF stay, including vaccines.
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