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Last Modified: 9/14/2022 Location: FL, PR, USVI Business: Part B

COVID-19 roster billing for Part B providers

CMS recently approved the new 2019 Coronavirus (COVID-19) vaccine and monoclonal antibody (mAb) infusion codes to help control the spread of COVID-19 during the public health emergency (PHE). During the PHE, Medicare will cover and pay for the administration of the vaccine.
First Coast has created a new standard roster form for COVID-19 vaccination and mAb infusion. This form is like the existing flu and pneumococcal forms and is available to providers through our website. We also provide an example below of the modified CMS-1500 (02/12) claim form, which serves as the cover document for the roster claim.
Use of this form simplifies roster billing for the COVID-19 vaccinations and mAb infusions:
The roster form allows up to five patients per page and can be submitted duplex (two-sided) to allow 10 patients per page.
Up to 10 pages per modified CMS-1500 (02/12) claim form will be accepted and scanned using Optical Character Recognition (OCR) technology.
Only bill for the vaccine administration codes when you submit claims to Medicare; don't include the vaccine product codes when vaccines are free.
Claims will be returned as unprocessable when this new standard roster form (linked below) is not submitted with the modified CMS-1500 (02/12) claim form or if the roster form/CMS-1500 claim form is incomplete.
Submit form for either COVID-19 vaccines or monoclonal antibody (mAb) infusions. Do not combine both on the same form.
COVID-19 vaccines -- For DOS on and AFTER December 11, 2020: COVID-19 vaccine: CMS-1500 (02/12) example with ICD-10 codes pdf file
Monoclonal antibody infusions -- For DOS on and AFTER November 10, 2020: Monoclonal antibody infusion: CMS-1500 (02/12) example with ICD-10 codes pdf file

Coding for COVID-19 roster bills

These charts contain the CPT and HCPCS coding information for the COVID-19 vaccines and mAb infusions, as well as their administration.
Effective Dates for COVID-19 Vaccines and their Administration during the PHE

 Code
CPT Short Descriptor
Labeler Name
Vaccine/Procedure Name
Effective Dates
91300*
SARSCOV2 VAC 30MCG/0.3ML IM
Pfizer
Pfizer-BioNTech COVID-19 Vaccine (Aged 12 years and older) (Purple Cap)
12/11/2020-TBD
0001A
ADM SARSCOV2 30MCG/0.3ML 1ST
Pfizer
Pfizer-BioNTech COVID-19 Vaccine (Purple Cap) Administration – First Dose
12/11/2020-TBD
0002A
ADM SARSCOV2 30MCG/0.3ML 2ND
Pfizer
Pfizer-BioNTech COVID-19 Vaccine (Purple Cap) Administration – Second Dose
12/11/2020-TBD
0003A
ADM SARSCOV2 30MCG/0.3ML 3RD
Pfizer
Pfizer-BioNTech COVID-19 Vaccine (Purple Cap) Administration – Third Dose
08/12/2021-TBD
0004A
ADM SARSCOV2 30MCG/0.3ML BST
Pfizer
Pfizer-BioNTech COVID-19 Vaccine (Purple Cap) Administration – Booster
09/22/2021-TBD
91301*
SARSCOV2 VAC 100MCG/0.5ML IM
Moderna
Moderna COVID-19 Vaccine (Aged 12 years and older) (Red Cap)
12/18/2020-TBD
0011A
ADM SARSCOV2 100MCG/0.5ML1ST
Moderna
Moderna COVID-19 Vaccine (Red Cap) Administration – First Dose
12/18/2020-TBD
0012A
ADM SARSCOV2 100MCG/0.5ML2ND
Moderna
Moderna COVID-19 Vaccine (Red Cap) Administration – Second Dose
12/18/2020-TBD
0013A
ADM SARSCOV2 100MCG/0.5ML3RD
Moderna
Moderna COVID-19 Vaccine (Red Cap) Administration – Third Dose
08/12/2021-TBD
91303*
SARSCOV2 VAC AD26 .5ML IM
Janssen
Janssen COVID-19 Vaccine (Aged 18 years and older)
02/27/2021-TBD
0031A
ADM SARSCOV2 VAC AD26 .5ML
Janssen
Janssen COVID-19 Vaccine Administration – First Dose
02/27/2021-TBD
0034A
ADM SARSCOV2 VAC AD26 .5ML B
Janssen
Janssen COVID-19 Vaccine Administration - Booster
10/20/2021-TBD
91304*
SARSCOV2 VAC 5MCG/0.5ML IM
Novavax
Novavax COVID-19 Vaccine, Adjuvanted (Aged 12 years and older)
7/13/2022-TBD
0041A
ADM SARSCOV2 5MCG/0.5ML 1ST
Novavax
Novavax COVID-19 Vaccine, Adjuvanted Administration – First Dose
7/13/2022-TBD
0042A
ADM SARSCOV2 5MCG/0.5ML 2ND
Novavax
Novavax COVID-19 Vaccine, Adjuvanted Administration – Second Dose
7/13/2022-TBD
91305*
SARSCOV2 VAC 30 MCG TRS-SUCR
Pfizer
Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Aged 12 years and older) (Gray Cap)
01/03/2022-TBD
0051A
ADM SARSCV2 30MCG TRS-SUCR 1
Pfizer
Pfizer-BioNTech COVID-19 Vaccine Pre-Diluted (Gray Cap) Administration - First dose
01/03/2022-TBD
0052A
ADM SARSCV2 30MCG TRS-SUCR 2
Pfizer
Pfizer-BioNTech COVID-19 Vaccine Pre-Diluted (Gray Cap) Administration - Second dose
01/03/2022-TBD
0053A
ADM SARSCV2 30MCG TRS-SUCR 3
Pfizer
Pfizer-BioNTech COVID-19 Vaccine Pre-Diluted (Gray Cap) Administration - Third dose
01/03/2022-TBD
0054A
ADM SARSCV2 30MCG TRS-SUCR B
Pfizer
Pfizer-BioNTech COVID-19 Vaccine Pre-Diluted (Gray Cap) Administration - Booster
01/03/2022-TBD
91306*
SARSCOV2 VAC 50MCG/0.25ML IM
Moderna
Moderna COVID-19 Vaccine (Aged 18 years and older) (Red Cap) (Low Dose)
10/20/2021-TBD
0064A
ADM SARSCOV2 50MCG/0.25MLBST
Moderna
Moderna COVID-19 Vaccine (Low Dose) Administration - Booster
10/20/2021-TBD
91307*
SARSCOV2 VAC 10 MCG TRS-SUCR
Pfizer
Pfizer-BioNTech COVID-19 Pediatric Vaccine (Aged 5 years through 11 years) (Orange Cap)
10/29/2021-TBD
0071A
ADM SARSCV2 10MCG TRS-SUCR 1
Pfizer
Pfizer-BioNTech COVID-19 Pediatric Vaccine (Orange Cap) - Administration - First dose
10/29/2021-TBD
0072A
ADM SARSCV2 10MCG TRS-SUCR 2
Pfizer
Pfizer-BioNTech Covid-19 Pediatric Vaccine (Orange Cap) - Administration - Second dose
10/29/2021-TBD
0073A
ADM SARSCV2 10MCG TRS-SUCR 3
Pfizer
Pfizer-BioNTech COVID-19 Pediatric Vaccine (Orange Cap) - Administration - Third dose
01/03/2022-TBD
0074A
ADM SARSCV2 10MCG TRS-SUCR B
Pfizer
Pfizer-BioNTech COVID-19 Pediatric Vaccine (Orange Cap) - Administration - Booster
05/17/2022-TBD
91308*
SARSCOV2 VAC 3MCG TRS-SUCR
Pfizer
Pfizer-BioNTech COVID-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap)
06/17/2022-TBD
0081A
ADM SARSCOV2 3MCG TRS-SUCR 1
Pfizer
Pfizer-BioNTech COVID-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) - Administration - First dose
06/17/2022-TBD
0082A
ADM SARSCOV2 3MCG TRS-SUCR 2
Pfizer
Pfizer-BioNTech COVID-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) - Administration - Second dose
06/17/2022-TBD
0083A
ADM SARSCOV2 3MCG TRS-SUCR 3
Pfizer
Pfizer-BioNTech COVID-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) - Administration - Third dose
06/17/2022-TBD
91309*
SARSCOV2 VAC 50MCG/0.5ML IM
Moderna
Moderna COVID-19 Vaccine (Aged 6 years through 11 years or aged 18 years and older) (Blue Cap with purple border) 50MCG/0.5ML
03/29/2022-TBD
0091A
ADM SARSCOV2 50 MCG/.5 ML1ST
Moderna
Moderna COVID-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) - Administration - First dose
06/17/2022-TBD
0092A
ADM SARSCOV2 50 MCG/.5 ML2ND
Moderna
Moderna COVID-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) - Administration - Second dose
06/17/2022-TBD
0093A
ADM SARSCOV2 50 MCG/.5 ML3RD
Moderna
Moderna COVID-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) - Administration - Third dose
06/17/2022-TBD
0094A
ADM SARSCOV2 50MCG/0.5 MLBST
Moderna
Moderna COVID-19 Vaccine (Aged 18 years and older) (Blue Cap with purple border) 50MCG/0.5ML Administration - Booster
03/29/2022-TBD
91311*
SARSCOV2 VAC 25MCG/0.25ML IM
Moderna
Moderna COVID-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) 250MCG/0.25ML
06/17/2022-TBD
0111A
ADM SARSCOV2 25MCG/0.25ML1ST
Moderna
Moderna COVID-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) - Administration - First dose
06/17/2022-TBD
0112A
ADM SARSCOV2 25MCG/0.25ML2ND
Moderna
Moderna COVID-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) - Administration - Second dose
06/17/2022-TBD
0113A
ADM SARSCOV2 25MCG/0.25ML3RD
Moderna
Moderna COVID-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) - Administration - Third dose
06/17/2022-TBD
91312
SARSCOV2 VAC BVL 30MCG/0.3M
Pfizer
Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product (Aged 12 years and older) (Gray Cap)
08/31/2022
0124A
ADM SARSCV2 BVL 30MCG/.3ML B
Pfizer
Pfizer-BioNTech COVID-19 Vaccine, Bivalent (Gray Cap) Administration – Booster Dose
08/31/2022
91313
SARSCOV2 VAC BVL 50MCG/0.5ML
Moderna
Moderna COVID-19 Vaccine, Bivalent Product (Aged 18 years and older) (Dark Blue Cap with gray border)
08/31/2022
0134A
ADM SARSCV2 BVL 50MCG/.5ML B
Moderna
Moderna COVID-19 Vaccine, Bivalent (Aged 18 years and older) (Dark Blue Cap with gray border) Administration – Booster Dose
08/31/2022
M0201**
COVID-19 vaccine home admin
N/A
COVID-19 vaccine administration inside a patient’s home; reported only once per individual home per date of service when only COVID-19 vaccine administration is performed at the patient’s home
6/8/2021-TBD
*Providers should not bill for product if it is received for free.
**Billable only in places of service 04, 06, 09, 12, 13, 14, 16, 19, 22, 33, 54, 55, 56, and 60. For additional billing information on M0201, review CMS’ infographic on Medicare payment for COVID-19 vaccine administration in the home external pdf file.
You can view the geographically adjusted payment rates here for 2020 and 2021.
Effective Dates for COVID-19 Monoclonal Antibodies and their Administration during the PHE

Code
CPT Short Descriptor
Labeler Name
Vaccine/Procedure Name
Effective Dates
Q0220*
Tixagev and cilgav, 300mg
AstraZeneca
Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available COVID-19 vaccine is not recommended due to a history of severe adverse reaction to a COVID-19 vaccine(s) and/or COVID-19 vaccine component(s), 300 mg
12/08/2021-TBD
Q0221*
Tixagev and cilgav, 600mg
AstraZeneca
Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available COVID-19 vaccine is not recommended due to a history of severe adverse reaction to a COVID-19 vaccine(s) and/or COVID-19 vaccine component(s), 600 mg
02/24/2022-TBD
M0220
Tixagev and cilgav inj
AstraZeneca
Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available COVID-19 vaccine is not recommended due to a history of severe adverse reaction to a COVID-19 vaccine(s) and/or COVID-19 vaccine component(s), includes injection and post administration monitoring
12/08/2021-TBD
M0221
Tixagev and cilgav inj hm
AstraZeneca
Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available COVID-19 vaccine is not recommended due to a history of severe adverse reaction to a COVID-19 vaccine(s) and/or COVID-19 vaccine component(s), includes injection and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency
12/08/2021-TBD
Q0222***
Bebtelovimab 175 mg
Eli Lilly
Injection, bebtelovimab, 175 mg
02/11/2022-TBD
M0222
Bebtelovimab injection
Eli Lilly
Intravenous injection, bebtelovimab, includes injection and post administration monitoring
02/11/2022-TBD
M0223
Bebtelovimab injection home
Eli Lilly
Intravenous injection, bebtelovimab, includes injection and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency
02/11/2022-TBD
Q0239*
bamlanivimab-xxxx
Eli Lilly
Injection, bamlanivimab, 700 mg
11/10/2020-04/16/2021
M0239
 
bamlanivimab-xxxx infusion
Eli Lilly
Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring
11/10/2020-04/16/2021
Q0240
Casirivi and imdevi 600mg
Regeneron
Injection, casirivimab and imdevimab, 600 mg
07/30/2021-TBD
M0240
Casiri and imdev repeat
Regeneron
Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses
07/30/2021-TBD
M0241
Casiri and imdev repeat hm
Regeneron
Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence, this includes a beneficiary's home that has been made provider-based to the hospital during the COVID-19 public health emergency, subsequent repeat doses
07/30/2021-TBD
Q0243*
casirivimab and imdevimab
Regeneron
Injection, casirivimab and imdevimab, 2400 mg
11/21/2020-TBD
M0243
Casirivi and imdevi inj
Regeneron
Intravenous infusion or subcuteaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring
11/21/2020-TBD
Q0244*
casirivi and imdevi 1200 mg
Regeneron
Injection, casirivimab and imdevimab, 1200 mg
06/03/2021-TBD
M0244
Casirivi and imdevi inj hm
Regeneron
Intravenous infusion or subcuteaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency
05/06/2021-TBD
Q0245*
bamlanivimab and etesevima
Eli Lilly
Injection, bamlanivimab and etesevimab, 2100 mg
02/09/2021-TBD
M0245
bamlan and etesev infusion
Eli Lilly
intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring
02/09/2021-TBD
M0246
bamlan and etesev infus home
Eli Lilly
Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency
05/06/2021-TBD
Q0247**
sotrovimab
GSK
Injection, sotrovimab, 500 mg
05/26/2021-TBD
M0247
sotrovimab infusion
GSK
Intravenous infusion, sotrovimab, includes infusion and post administration monitoring
05/26/2021-TBD
M0248
sotrovimab inf, home admin
GSK
Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency
05/26/2021-TBD
Q0249**
Tocilizumab for COVID-19
Genentech
Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg
06/24/2021-TBD
M0249
Adm Tocilizu COVID-19 1st
Genentech
Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose
06/24/2021-TBD
M0250
Adm Tocilizu COVID-19 2nd
Genentech
Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose
06/24/2021-TBD
*Providers should not bill for product if it is received for free.
**The government won’t provide this drug for free.
***Q0222 – Eli Lilly started commercial distribution on August 15. For dates of service on or after August 15, claims for commercially acquired treatments may be allowed at the new payment rate of $2,394.00. You may have supplies of both the United States Government (USG)-procured and commercially procured product. Providers should only bill above a nominal amount for the commercially procured product. You can identify the commercially procured vials by the batch number D534422 and other batch numbers will be issued. Review the batch number prior to claim submission to determine if the product was USG procured or commercially procured and ensure appropriate billing.
You can view the geographically adjusted payment rates here for 2020 and 2021.

COVID-19 roster billing

Roster bills can be submitted on paper or electronically. If billing for both COVID-19 vaccinations and mAb infusions, these need to be submitted on separate claims. Do not bill for the other service on the same claim. Do not use roster billing for a single beneficiary.
Modified CMS-1500 (02/12) claim form instructions
Complete a modified CMS-1500 (02/12) claim form containing the information in the table below to serve as a cover document to the roster bill.

Item Number
Information to Enter
1 -- Type of insurance
"X" in Medicare block
2 -- Patient's Name
Enter "SEE ATTACHED ROSTER"
11 -- Insured's Policy Group or Federal Employees' Compensation Act (FECA) Number
Enter "NONE"
20 -- Outside Lab
"X" in the NO block
21 -- Diagnosis or Nature of Illness or Injury
For vaccine billing:
Line A: Enter "Z23"
Enter "0" for ICD Indicator between dotted lines
For mAb billing:
Line A: Enter appropriate diagnosis coded to highest level of specificity (U071 – use as appropriate)
Enter "0" for ICD Indicator between dotted lines
24B -- Place of Service (POS)
Enter "60"
Note: POS code "60" must be used for roster billing
24D -- Procedure, Services, or Supplies
NOTE; Medicare will not provide payment for the COVID-19 vaccine or mAb products that healthcare professionals receive for free, as will be the case upon the product's initial availability in response to the COVID-19 PHE. Providers should not bill for product if it is received for free.
24E -- Diagnosis Pointer (Code)
Enter "A"
24F -- Charges
List charge for each service *Not total for all patients
If no charge, enter "$0.00"
NOTE; Medicare will not provide payment for the COVID-19 vaccine or mAb products that healthcare professionals receive for free, as will be the case upon the product's initial availability in response to the COVID-19 PHE. Providers should not bill for product if it is received for free.
27 -- Accept Assignment?
Enter "X" in YES block
29 -- Amount Paid
Enter "$0.00"
31 -- Signature of Physician or Supplier
Entity's representative must sign
32 -- Service Facility Location Information
Name, address and ZIP of location where services were rendered
32a -- Service Facility Location number
National Provider Identifier (NPI) of service facility
33 -- Billing Provider Information & Phone Number
Enter billing provider information and phone number
33a -- Billing Provider NPI
Enter the NPI of the billing provider or group
Attach the standard COVID-19 Vaccines or Monoclonal Antibody Infusion Roster Form with the following information completed:
Provider's name and NPI
Date of service
Beneficiary
Medicare number
Date of birth
Signature or stamped "signature on file"
Name (last, first, middle initial)
Gender
Address
Note: If the beneficiary's actual signature cannot be obtained, the phrase "signature on file" can be used if the provider has a signed authorization on file from the beneficiary to bill Medicare for services.

Roster forms

First Coast houses the roster forms on the Forms page of our website, under the "Immunization roster billing" section.

References

Returned claims

If a claim returns for OCR references, you will receive notification through your normal provider voucher or reconciliation file with the appropriate returned information. It is your responsibility to verify that all information is complete before resubmitting the claim.
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.