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Last Modified: 11/25/2022 Location: FL, PR, USVI Business: Part A, Part B

Billing COVID-19 vaccine and administration FAQs

Please see the FAQs below for billing COVID-19 vaccines and administrations.

Billing vaccines, infusions, and administrations

Q1. What services can currently be billed for the vaccine and infusions?
A1. When COVID-19 vaccine and monoclonal antibody (mAb) doses are provided by the government without charge, you can only bill for the vaccine and mAb administrations. Don’t include the vaccine or drug codes on the claim when the vaccines and mAb are free.
Note: You may submit the billed amount as $0.01 if your software requires submission of the vaccine or infusion drug code with the administration.
Q2. For Part A billing, what revenue code should be used?
A2. The revenue codes 0771 (preventive care services, vaccine administration) or 0636 (pharmacy, drugs requiring detailed coding) should be used. Don’t include the vaccine or drug codes on the claim when the vaccines and mAb are free.
Q3. Can other services be billed on the same Part B claim as the administration?
A3. For individual claims, if the beneficiary receives services on the same day as the vaccine or infusion administration, the services can be billed if they are medically necessary and distinct, separate services from the vaccine or infusion. The services should be billed with applicable modifiers (i.e., modifier 25).
If you are billing the services on a roster bill claim, do not bill for any other services on the roster bill.
Q4. Does the CS modifier need to be on the administration claim?
A4. No, the CS modifier should not be reported on the vaccine and/or mAb infusion administration claims. Medicare beneficiaries pay nothing for the COVID-19 vaccine and mAb administrations. There is no deductible or copayment/coinsurance applied.
Q5. As the primary physician, is there a code we can bill to inform that the patient has received the COVID-19 vaccine?
A5. No, there is not a code for reporting the patient has received the vaccine. You can bill for the administration if you administer the vaccine.
Q6. Do claims for casirvimab and imdevimab require the National Drug Code (NDC) numbers?
A6. When COVID-19 mAb doses are provided by the government without charge, you can only bill for the administration. Claims for the administration do not require the NDC numbers.
Q7. Can a primary care doctor advise their patient to go to the emergency department (ED) for mAb infusion? Can the ED doctor then examine the patient and determine eligibility for mAb infusion?
A7. Yes, the primary care doctor can advise their patients to go to the ED for mAb infusion. The patient must meet requirements for receiving the mAb infusion and the documentation should include the name of the practitioner who ordered or made the decision to administer the infusion.
Q8. Does a single Part A vaccine administration claim require an attending physician?
A8. An attending physician is required on all Part A claims including the COVID-19 vaccine and mAb infusion claims. If there is no attending physician information on the claim, it will be returned.
Q9. We are a critical access hospital (CAH) with a hospital-based clinic. Should we bill for the administration fees on the claim form for payment since we are cost-based or keep a roster for the free vaccine?
A9. CAHs are listed among the providers of services who may administer and submit institutional claims to the MACs for vaccines. CAHs will follow the same instructions for any hospital facility and would bill on type of bill (TOB) 12x or 13x.
Q10. We are providing the vaccine and billing for the administration fee. Do we need keep a roster for the vaccine even though it was free?
A10. No, you are not required to keep a roster of who the vaccine was administered to.
Q11. Is a positive COVID-19 test required for administering mAb?
A11. Yes, mAb is for the treatment of patients who have tested positive for COVID-19. This treatment is for mild-to-moderate COVID-19 in adults and pediatric beneficiaries who are at high risk for progressing to severe COVID-19 or hospitalization. For more information on the Emergency Use Authorization, please visit the CMS page Monoclonal Antibody COVID-19 Infusion external link.
Q12. Is a clinical trial number required on claims for mAb?
A12. No, clinical trial numbers are not required on mAb claims.
Q13. What are the supervision requirements for infusion administration under Part B billing?
A13. The mAb EUA fact sheets do not list supervision requirements. The fact sheets do provide requirements for the infusion to be prepared and administered by a qualified healthcare personnel and the patient must be clinically monitored during administration and observed for at least one hour after infusions is complete. For more information on the EUA, please visit the CMS page Monoclonal Antibody COVID-19 Infusion external link.
Q14. For hospital claims, can we bill emergency room services along with the infusion administration or does the administration need to be on a claim all by itself?
A14. In the place of service emergency room, the mAb service is submitted on the Part A outpatient hospital claim. If the beneficiary receives services on the same day as mAb, the services can be billed if they are distinct, separate services from the infusion.
Q15. Inpatient claims are usually billed with TOB 11X. Are vaccine administrations required to be submitted on TOB 12X claims?
A15. For hospitalized patients, payment for COVID-19 vaccines are made separately from the Diagnosis-Related Group (DRG) rate and not allowed on TOB 11X claims. The valid TOBs include 12X, 13X, 22X, 23X, 34X, 72X, 75X, 81X, 82X, and 85X.
Q16. Are condition codes (CCs) A6 and 78 required for Part A claims?
A16. The CC A6 should be included on all Part A claims for vaccine administration. The CC 78 should also be included when billing original Medicare for Medicare Advantage beneficiary claims.
Q17. Can specialists administer the vaccine or is it limited to primary care physicians?
A17. For non-institutional claims, the vaccine administration can be billed by these eligible professionals: physician, non-physician practitioners, clinic/group practice, pharmacy, and mass immunizer. The specialist can perform and bill the vaccine administration if they are enrolled in the Medicare program and meet eligibility requirements.

Claims for Medicare Advantage (MA) patients

Q1. Are claims for mAb infusions for MA patients to be submitted to original Medicare?
A1. Yes, claims for vaccines or infusions administered to MA patients for dates of service in 2020 and 2021 should be submitted to original Medicare. Claims for vaccines and infusion administrations administered to MA patients for dates of service in 2022 should be submitted to the MA. Contact the MA for information on billing and coding services in 2022.
Q2. When billing original Medicare for MA patients, can the claims be submitted as roster bills or must they be submitted as individual claims?
A2. For Part A, these claims must be submitted as individual claims. Ensure you include the CC 78 on the Part A claim to indicate it is for a MA beneficiary.
For Part B, these claims can be submitted as individual or roster claims.
Q3. When a patient receives the service in the emergency department (ED), are providers splitting the claim between the MA plan and original Medicare, only billing the infusion to Medicare?
A3. Yes, the claim for the infusion administration should be submitted to original Medicare. Continue normal billing practices for other services. Please keep in mind, Medicare will not pay for the monoclonal antibody products that health care providers receive for free. When the product is received for free, submit only the administration code on the claim.
Q4. When submitting claims to original Medicare for MA beneficiaries, are we required to provide the original Medicare Beneficiary Identifier (MBI) on the individual claims?
A4. For Part A and Part B claims, submit the claim with the MBI. If the patient does not have the Medicare card or MBI, you can use the MBI Lookup in the SPOT. SPOT is First Coast’s free online portal. Review the SPOT webpage for more information.
Q5. Does the Medicare secondary payer (MSP) questionnaire need to be completed when billing First Coast for the MA enrolled patients?
A5. No, you are not required to ask the MSP questionnaire or to collect, maintain, or report this information for MA beneficiaries.

Roster billing

Q1. For Part B billing, are we required to submit a CMS-1500 claim form with the roster bill?
A1. Yes, you are required to submit a modified CMS-1500 claim form with the roster bill. Review the article COVID-19 roster billing for Part B providers to identify CMS-1500 claim form and roster billing requirements.
Q2. What form should federally qualified health centers (FQHCs) use?
A2. There is no roster form for rural health clinics (RHCs) or FQHCs. The simplified roster claims filing procedure applies to providers other than RHCs and FQHCs that conduct mass immunizations.
Independent and provider-based RHCs and FQHCs do not include charges for influenza virus, pneumococcal, or COVID-19 vaccines on form CMS-1450. Administration of these vaccines does not count as a visit when the only service involved is the administration of the vaccine(s).
Since independent and provider-based RHCs and FQHCs do not submit individual form CMS-1450s for vaccines, they do not utilize the simplified billing process. Instead, payment is made for the vaccine at the time of cost settlement.
If there was another reason for the visit, the RHC/FQHC should bill for the visit without adding the cost of the vaccines to the charge for the visit on the bill. AB MACs (A) pay at the time of cost settlement and adjust interim rates to account for this additional cost if they determine that the payment is more than a negligible amount.
A3. Yes, the roster bill claim should include only the administration code.

Enrolling to roster bill

Q1. What is required to enroll as a mass immunizer to roster bill?
A1. You must apply to become enrolled as a mass immunizer. You can initiate temporary billing privileges by calling the provider enrollment hotline at 855-247-8428. You will receive the approval or rejection during the call. For more information on contacting the provider enrollment hotline, review the article Are you enrolled to bill COVID-19 vaccine and monoclonal antibody administrations?
Q2. Do Part A enrolled providers need to enroll as a different provider type to submit roster bills?
A2. If the Part A provider will continue to bill Part A, then separate enrollment is not required.
If the billing will be submitted to Part B, you must separately enroll as a mass immunizer. You can initiate temporary billing privileges by calling the provider enrollment hotline at 855-247-8428. You will receive the approval or rejection during the call. For more information on contacting the provider enrollment hotline, review the article Are you enrolled to bill COVID-19 vaccine and monoclonal antibody administrations?
Q3. Do Part B enrolled providers need to enroll as a different provider type to submit roster bills?
A3. If the Part B provider is already enrolled as a different provider type, you must separately enroll as a mass immunizer. You can initiate temporary billing privileges by calling the provider enrollment hotline at 855-247-8428. You will receive the approval or rejection during the call. For more information on contacting the provider enrollment hotline, review the article Are you enrolled to bill COVID-19 vaccine and monoclonal antibody administrations?

Additional information

Please visit First Coast’s Coronavirus (COVID-19) webpage for more information.

Questions

Questions regarding topics not currently defined in CMS or First Coast published resources related to COVID-19 services can be sent to COVID-19@CMS.HHS.gov.
If you have questions regarding Medicare processes, please contact us.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.