COVID-19 Vaccine Billing Guidance (April Update)

PAAS National® has seen a few COVID-19 vaccine audits since pharmacies began billing and administering within the last few months. This article contains some reminders and updates from our January 2021 Newsline COVID-19 Vaccine Billing Guidance. As a general rule, vaccine claims are lower risk for PBM audit; however, audits are always possible, and you should be prepared with good documentation. PAAS highly recommends creating a placeholder “prescription” with all required elements for your records – many pharmacies already do this when billing for other vaccines under protocol. Additionally, it will be necessary to document the administration through a vaccine administration record as well as provide the patient with an Emergency Use Authorization (EUA) fact sheet (in place of a vaccine information sheet). Be sure to submit the correct quantity, days’ supply, SCC code and CPT code depending on which vaccine you are administering. Please see the chart below for a reference.

The coverage for COVID-19 vaccine may be under the pharmacy benefit (via NCPDP standard) or the medical benefit (via CPT codes). Here is a summary of billing information known to PAAS:

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Pharmacy Benefit* Medical Benefit
Vaccine NDC-11 Billing Quantity & Units Days’
Supply
Dose 1 Dose 2 CPT Codes Dose 1 Dose 2
Pfizer-BioNTech1 59267-1000-01 0.3 mL 1 SCC-02 to indicate “first dose” SCC-06 to indicate “final dose” 91300 0001A 0002A
Moderna2 80777-0273-10 0.5 mL 1 91301 0011A 0012A
Janssen3 59676-0580-05 0.5 mL 1 N/A 91303 0031A single-dose N/A

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(1) Pfizer BioNTech vaccine has a package size of 1.8 mL and will deliver 6 doses of 0.3 mL

(2) Moderna vaccine has a package size of 5 mL and will deliver 10 doses of 0.5 mL

(3) Janssen vaccine has a package size of 2.5 mL and will deliver 5 doses of 0.5 mL

*NCPDP also recommends that pharmacy claims will need to submit the following for ZERO-COST vaccines:

  1. Professional Service Code (440-E5) of “MA” (Medication Administered)
  2. Ingredient Cost Submitted (409-D9) of $0.00 or $0.01
  3. Incentive Amount Submitted (438-E3) to request payment for administration
    • Effective on March 15, 2021, the Medicare Part B payment rate for immunizers will be $40 to administer each dose of a COVID-19 vaccine
    • The exact payment rate for administering a COVID-19 vaccine can depend on the type of entity that provides the service and will be geographically adjusted based on where the service is provided.
  4. Basis of Cost Determination (423-DN) of “15” (free product or no associated cost)

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Jennifer Ottman, CPhT
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