We are working to ensure minimal impacts to claims processing for COVID-19 vaccine and infusion administrations. We are actively reviewing data from claim errors and providing education to prevent claim payment delays. This billing alert series is based on those claim errors and provides guidance for billing Medicare along with tips for administrating the COVID-19 vaccine or antibody infusions.
A. Medicare Advantage beneficiaries to traditional Medicare
B. Claims rejecting for Medicare Advantage beneficiaries require CC 78
C. Multiple PTAN linked to single NPI claim issue
D. Place of service (POS) for Part B claims
E. Billing the administration codes
F. Medicare secondary payer (MSP)
G. Part B entitlement
Comprehensive information on COVID-19 vaccine and mAb infusions can be referenced on our COVID-19 vaccine and monoclonal antibodies specialty page.
CMS provided special guidance for Medicare Advantage plan patients. For 2020 and 2021, submit the vaccine or infusion administration claims for Medicare Advantage plan enrollees to traditional Medicare using the Medicare Beneficiary Identifier (MBI) for processing and payment.
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.
Note: If the patient does not have a Medicare card with their MBI, you can obtain the MBI by using our MBI Look-up, available in Novitasphere (JH) (JL). You will need the patient’s full name, social security number, and date of birth.
Medicare Advantage claims require the condition code (CC) 78 to be reported on Part A UB-04 institutional claims to avoid the claim from rejecting. Do not submit roster billing since the Fiscal Intermediary Shared System/direct data entry does not allow CC 78.
Note: This does not apply to FQHCs and RHCs, please see specific information for FQHCs and RHCs.
Reference
Posted 03/26/2021
Recent data analysis shows an increase in Part A claims for COVID-19 vaccines and infusions being rejected for patients enrolled in a Medicare Advantage plan. These claims are rejecting with reason code U5233.
When billing for the COVID-19 vaccines and/or infusion products to Medicare Part A, you must include CC 78 (New coverage not implemented by Medicare Advantage) on the claim. For COVID-19 vaccine claims for Medicare Advantage plan beneficiaries, report both CC A6 (100% payment) and CC 78.
If your claim was rejected for missing CC 78, please correct, and resubmit your claim.
References
Posted 03/02/2021
When submitting claims for COVID-19 testing, vaccine or mAb infusion administrations to adequately ensure minimal impacts to claims processing, Medicare requires claims to contain NPI.
NPIs reported on the claims are cross walked to the Medicare assigned PTAN. Claims processing is based on a one-to-one match between the two. When a unique match cannot be made, your claim may be denied.
For organizations who have multiple PTANs linked to one single NPI, we recommend providing the taxonomy code on the initial claim submission. If unsure what taxonomy code to use, view your current taxonomy code on the National Plan and Provider Enumeration System (NPPES). This will ensure the claim processes with the correct PTAN. To learn how to report the taxonomy code on the claim, refer to X12N 837 5010 Testing tips for vendors (JH) (JL).
Note: Centralized billers and mass immunizers do not have assigned taxonomy codes for their specialty types. It is best practice to verify the taxonomy code selected on NPPES. In addition, both specialties have been approved to use pharmacy taxonomy codes on their claims.
If your claims deny for this reason, and you did not previously report the taxonomy code, we recommend you resubmit your claims using the taxonomy code to assist with assigning the correct PTAN.
References
Posted 02/03/2022
When selecting the POS code to bill on your Part B claim, you should consider several factors.
Where are the services being rendered?
Is it an extension site (i.e., tent, transitioned gymnasium, or a converted non-clinical location)?
If it is an extension site, who established the site? Clinic/group practice or hospital?
Who’s providing the supplies and materials for the services being rendered?
Is the clinic/group practice or hospital staff rendering the service?
These questions will help you in determining who should bill for the service and the POS code to use on Part B claims. To facilitate correct billing and prevent duplicate billing, we recommend discussion between the providers involved in the service, including the hospital, hospitalist groups, clinic/groups practices, etc.
Reference
Medicare Claims Processing Manual, Pub. 100-04, Chapter 26 - Completing and Processing Form CMS-1500 Data Set, Section 10.5 - Place of Service Codes (POS) and Definitions
See special considerations for outpatient hospital departments
Scenario #1
A patient presents to the emergency room (ER) with mild to moderate COVID-19 symptoms and a positive test result from a previously administered test. The attending ER physician examine the patient and orders mAb. The nursing staff administers the mAb infusion. Since the location is the ER and the hospital nursing staff is administering the mAb, we expect the hospital to bill for the mAb infusion administration to Part A.
The ER physician would bill Part B with POS code 23 (ER – Hospital) and the applicable evaluation and management (E/M) service. If a Part B claim is submitted for mAb in POS 19 (off campus – outpatient hospital), 22 (on campus – outpatient hospital) or 23 (ER – hospital), the service will be denied since it should be submitted to Part A.
Reference
COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing Section Q. Physician Services
Scenario #2
A clinic/group practice has set up a temporary site for administering COVID-19 vaccines. The clinic/group practice is providing the supplies and staff for administering the vaccines. The location for the temporary site is on the campus of a nearby hospital. Although the hospital has provided the location for the temporary site, the hospital is not providing supplies nor staff for providing the vaccines.
The hospital would not bill for any services since they are not providing the supplies or staff. The clinic/group practice would bill Part B for the administration of the vaccine and use POS code 11 (office) since the temporary location is an extension of their practice.
Reference
COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing Section Q. Physician Services
Scenario #3
A clinic/group practice has contracted with a hospital to provide care for patients that have tested positive for COVID-19 and has mild to moderate symptoms. The hospital has set up a temporary location in a repurposed convention center to administer mAb infusion as an outpatient service. The hospital is providing the supplies and nursing staff. Physicians and nonphysician practitioners from the clinic/group practice are working at the temporary location to examine the patients and order the mAb infusion. The hospital nursing staff administers the mAb infusion based on the practitioner’s order. The hospital would bill for the mAb infusion to Part A. The contracted physician that ordered the mAb would bill Part B for the applicable E/M service with POS code 19 (off campus – outpatient hospital) or 22 (on campus – outpatient hospital) since the temporary site is an extension of the hospital’s outpatient department.
Reference
COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing Section BB. Drugs & Vaccines under Part B (Question 19)
Posted 02/05/2021
When COVID-19 vaccine and monoclonal antibody doses are provided by the government free of charge, only bill for the administration. Don't include the vaccine or infusion drug codes on the claim when the vaccines or infusion drugs are free. Single claim or roster claim billing should include only the administration codes.
Note: If your software requires you to submit the vaccine or infusion drug codes with the administrations, submit the billed amount as $0.01.
Reference
COVID-19 vaccine and monoclonal antibody (mAb) infusion FAQs
Posted 01/26/2021
The provider must determine if the Medicare patients have other insurance, such as employer health insurance, or coverage through a spouse’s employer health insurance and if Medicare pays first or second.
CMS has clarified that you must gather information both from patients with Original Medicare and from patients enrolled in Medicare Advantage plans. All providers administering COVID 19 vaccines and/or mAb infusions should verify insurance information.
Providers billing for Part A UB-4 institutional services are required to determine whether Medicare is a primary or secondary payer for Medicare patients when presenting for inpatient and outpatient encounters. The model questionnaire in the Medicare Secondary Payer Manual, Pub. 100-05, Chapter 3, Section 20.2.1 lists the type of questions that should be asked for every admission, outpatient encounter, or start of care.
Note: If you can submit and receive a X12 270/271 transaction, you can use this for confirming insurance information in place of the MSPQ. You can verify with the Medicare beneficiary if the information is valid or if there has been a change instead of asking the questions. However, you must ask the questions if there has been a change or the beneficiary is unsure.
References
Posted 01/26/2021
Revised 03/30/2021
Part of your responsibility as a provider is to verify entitlement prior to claim submission and make a good faith effort to figure out who is primary and who is secondary. There are many self-service options available to verify eligibility:
FISS Option 10 – Beneficiary / CWF (Part A only):
Interactive voice response (IVR):
The Medicare beneficiary must have Part B Medicare for the vaccine to be reimbursed by Medicare. Because it will be covered under Part B, the COVID vaccine and its administration will not be covered under Part D. In the absence of Part B coverage, the provider should bill the insurance the beneficiary does have and if there is no other insurance, the provider can request reimbursement for the administration through the provider relief fund.
Posted 01/26/2021