Transcription
4WYORKTEOFORTUNITYKATHY HOCHULGovernorDepartmentof HealthMARY T. BASSETT, M .D., M.P.H.CommissionerKRISTIN M. PROUDActing Executive Deputy CommissionerNew York State MedicaidCoverage Policy and Billing Guidance for the Administrationof COVID-19 VaccinesUpdates as of 7-18-2022 are highlighted in yellow.This guidance sets forth New York State (NYS) Medicaid’s reimbursement policyfor the administration of COVID-19 vaccines approved by the FDA or authorizedfor emergency use and instructions for providers to bill the cost ofadministration of authorized COVID- 19 vaccine. Information about vaccinesreceiving approval or emergency use authorization (EUA) by the FDA can be found esponse/coronavirus-disease2019- covid-19/covid-19-vaccinesNYS Medicaid’s policy for the administration of COVID-19 vaccine will continue toremain in effect in accordance with the Public Readiness and EmergencyPreparedness Act (PREP Act). As additional COVID-19 vaccines become availableunder an EUA, or are otherwise approved by the FDA, this billing guidance will beupdated as needed.I. NYS Medicaid Coverage PolicyThis coverage policy applies to both Medicaid fee-for-service (FFS) andMedicaid Managed Care (MMC).A. NYS Medicaid Will Not Reimburse for the Cost of COVID-19 Vaccine1. Payment will not be made to NYS Medicaid providers for the cost of COVID-19vaccine because the vaccine is available at no cost to providers. Providersmust not bill the Current Procedural Terminology (CPT) code for the vaccine.2. In order to obtain COVID-19 vaccine at no cost, Medicaid enrolled providersmust be legally authorized to administer the vaccine and also enroll as COVID19 vaccine providers with the Centers for Disease Control and Prevention(CDC), the NYS Department of Health Bureau of Immunization, or the NYCDepartment of Health and Mental Hygiene (NYCDOHMH) Bureau ofImmunization. Such providers are considered qualified providers by theMedicaid program for the purpose of COVID-19 vaccine administration.3. For information on how to enroll in the NYS COVID-19 Vaccination ProgramEmpire State Plaza, Corning Tower, Albany, NY 12237 Ihealth.ny.gov
and how to register for the NYSIIS or CIR, please ccine-information-providers.4. Note that this program is distinct from the Vaccines for Children (VFC)Program and separate enrollment is required.B. Reimbursement for Administration of COVID-19 Vaccines1. The NYS Medicaid program, including the Medicaid FFS program and MMC, willreimburse NYS Medicaid enrolled and qualified providers for the administrationof COVID-19 vaccines.2. Reimbursement for administration of COVID-19 vaccines may be based on apatient-specific order or non-patient specific order (“standing order”). Theseorders must be kept on file by the provider. Standing orders enableassessment and vaccination of the patient without the need for clinicianexamination or a patient-specific order from the attending provider at the timeof the patient interaction. For more information, please /documents/2020/12/joint vaccine administration 12-15 715pm.pdf3. The ordering provider’s National Provider Identifier (NPI) is required onthe Medicaid claim. Ordering providers, including MMC networkproviders, are required to be enrolled in the NYS Medicaid program(except pharmacists).4. Providers are prohibited from charging Medicaid members a co-payment orany cost-sharing responsibility for the COVID-19 vaccine or the administrationof the COVID-19 vaccine.5. Providers must not bill NYS Medicaid for the administration of the COVID-19vaccine to members who are also enrolled in Medicare. Dually eligibleenrollees will continue to access full coverage of immunization servicesthrough Medicare.C. Coverage of Preventative Counseling for the COVID-19 VaccineEffective December 1, 2021, NYS Medicaid, including MMC Plans, will reimburse qualified NYSMedicaid enrolled providers for COVID-19 vaccination counseling to Medicaid members toencourage the administration of COVID-19 vaccines. NYS Medicaid has updated the coverageand billing guidance for COVID-19 vaccination counseling. The updated COVID-19 vaccineguidance document Updated Coverage Criteria for COVID-19 Vaccine Counseling can be foundon the COVID-19 Guidance for Medicaid Providers webpage.II. NYS Medicaid FFS Billing Instructions and FeesThe following billing instructions and fees apply to Medicaid FFS.
A. Qualified Hospital Outpatient Departments, Diagnostic and TreatmentCenters, Federally Qualified Health Centers (including School Based HealthCenters designated as Federally Qualified Health Centers), Office-BasedPractitioners, and Ambulance Providers1. NYS Medicaid enrolled hospital outpatient departments, free-standingdiagnostic and treatment centers (D&TCs), Federally Qualified HeathCenters (FQHCs), School Based Health Centers designated as an FQHC(SBHC/FQHC), private office-based practitioners, and ambulanceproviders can bill NYS Medicaid for COVID-19 vaccine administrationadministered to NYS Medicaid FFS members in accordance with Table 1below.Table 1FeeEffectivefor Datesof Serviceon orAfter 40.004/1/2021 40.004/1/20218/12/2021 40.008/12/20219/22/2021 40.009/22/2021 40.004/1/2021 40.004/1/20218/12/2021 40.008/12/2021N/A10/20/2021 40.0010/20/2021N/A3/29/2022 40.003/29/2022CPTCodeManufacturer & COVID-19 VaccineAdministration CPT Code – ShortDescriptionFee0001APfizer-BioNTech - ADM SARSCOV230MCG/0.3ML - 1st Dose 13.230002APfizer-BioNTech - ADM SARSCOV230MCG/0.3ML - 2nd Dose 13.230003APfizer-BioNTech - ADM SARSCOV230MCG/0.3ML – 3rd DoseN/A0004APfizer-BioNTech - ADM SARSCOV230MCG/0.3ML – Booster DoseN/A0011AModerna - ADM SARSCOV2100MCG/0.5ML - 1st Dose 13.230012AModerna - ADM SARSCOV2100MCG/0.5ML - 2nd Dose 13.230013AModerna - ADM SARSCOV2100MCG/0.5ML – 3rd DoseN/A0064AModerna – ADM SARSCOV250MCG/0.25ML – Booster Dose0094AModerna – ADM SARSCOV250MCG/0.5 ML – Booster DoseEffectivefor Datesof 2/18/2020to3/31/202112/18/2020to3/31/2021
0031AJanssen - ADM SARSCOV2 VACAD26 .5ML 13.232/27/2021to3/31/2021 40.004/1/20210034AJanssen - ADM SARSCOV2 VACAD26 .5ML - Booster DoseN/A10/20/2021 40.0010/20/20210051APfizer-BioNTech – ADM SARSCV230MCG TRS-SUCR – 1st DoseN/A1/3/2022 40.001/3/20220052APfizer-BioNTech – ADM SARSCV230MCG TRS-SUCR – 2nd DoseN/A1/3/2022 40.001/3/20220053APfizer-BioNTech – ADM SARSCV230MCG TRS-SUCR – 3rd DoseN/A1/3/2022 40.001/3/20220054APfizer-BioNTech – ADM SARSCV230MCG TRS-SUCR – Booster DoseN/A 40.001/3/20221/3/2022Pfizer-BioNTech - ADM SARSCOV210MCG/0.2ML Trs-Sucr (ages 5-11)N/A11/3/2021 40.00 11/3/2021st1 DosePfizer-BioNTech - ADM SARSCOV20072A 10MCG/0.2ML Trs-Sucr (ages 5-11)N/A11/3/2021 40.00 11/3/20212nd DosePfizer-BioNTech - ADM SARSCOV20073A 10MCG/0.2ML Trs-Sucr (ages 5-11)N/A1/3/2022 40.00 1/3/20223rd DosePfizer-BioNTech - ADM SARSCOV20074A 10MCG/0.2ML Trs-Sucr (ages 5-11)N/A5/17/2022 40.00 5/17/2022Booster DosePfizer-BioNTech - ADM SARSCOV20081A 3MCG/0.2ML Trs-Sucr (6mos – 4yrs)N/A6/17/2022 40.00 6/17/20221st doseIPfizer-BioNTech - ADM SARSCOV20082A 3MCG/0.2ML Trs-Sucr (6mos – 4yrs)N/A6/17/2022 40.00 6/17/20222nd doseIPfizer-BioNTech - ADM SARSCOV20083A 3MCG/0.2ML Trs-Sucr (6mos – 4yrs)N/A6/17/2022 40.00 6/17/20223rd doseIModerna - ADM SARSCOV2I0111A 25MCG/0.25ML (6mos – 5yrs) – 1stN/A6/17/2022 40.00 6/17/2022DoseIModerna - ADM SARSCOV2I0112A 25MCG/0.25ML (6mos – 5yrs) – 2ndN/A6/17/2022 40.00 6/17/2022DoseINOTE: Practitioner and Ordered Ambulatory claims submitted prior to June 1, 2021 for dates ofservice on or after April 1, 2021 that were paid at 13.23 will be automatically reprocessed at thenew 40.00 administration fee. Providers do not need to submit claim adjustments.0071A
2. Hospital outpatient departments, D&TCs, FQHCs and SBHC/FQHCsshould bill an ordered ambulatory claim for COVID-19 vaccineadministration.Note: SBHC/FQHCs providing COVID-19 vaccine administration toMedicaid FFS and Managed Care members will be required to append the“HA” modifier to the appropriate vaccine administration CPT code fromTable 1 above.3. Office-based practitioners should bill a professional claim for COVID-19vaccine administration.4. The COVID-19 vaccine administration CPT codes above include the actualwork of administering the vaccine, including all necessary counseling providedto patients and/or caregivers for the dose administered, required vaccinationreporting, and updating of electronic records. See section C above regardingCOVID-19 vaccine counseling.5. NYS Medicaid enrolled providers, if within their scope of practice, can bill an Evaluationand Management (E&M) visit on the same day as the COVID-19 vaccineadministration, when additional services are provided that are beyond the componentsrepresented in the COVID-19 vaccine administration code, and when all of the keycomponents of the E&M code have been provided and documented.6. Hospital outpatient departments, D&TCs, and FQHCs providingcomprehensive clinic services in addition to and beyond the scope of theCOVID-19 vaccine administration service (see #4 & #6 above) can bill anappropriate APG or PPS claim for the medical services provided and can bill aseparate ordered ambulatory claim for the COVID-19 vaccine administration.7. When the only service provided is the COVID-19 vaccine administration, onlyan ordered ambulatory claim for the vaccine administration can be submitted.8. Ambulance providers have been assigned Category of Service code (COS)“0282” and should bill a professional claim using the COVID-19 vaccineadministration codes in Table 1. Ambulance provider claims for COVID-19vaccine administration should be identified as a non-emergency service byreporting the “Emergency Indicator” as “N”. No prior approval/priorauthorization is required.NOTE: As of June 25, 2021, with the expiration of the New York State DeclaredDisaster Emergency, ambulance providers may only bill for Covid-19 vaccinationsadministered by paramedics.9. Medicaid providers administering a COVID-19 vaccine to Medicaid members withFamily Planning only coverage should bill a separate claim for COVID-19 vaccineadministration using ICD-10 diagnosis code Z23 (encounter for immunization) asthe primary diagnosis on the claim with the appropriate COVID-19 vaccineadministration CPT code from Table 1 representing the COVID-19 vaccineadministered.B. Qualified Pharmacies
The following billing instructions and fees apply to the Medicaid FFS program.1. Pharmacies affiliated with a point-of-dispensing (POD) site, such as askilled nursing facility, residential facility, or mobile vaccination site, musthave the pharmacy operating site enrolled with NYS Medicaid FFS.The pharmacy must submit via NCPDP D.0 in the Claim Segment field 436-E1(Product/Service ID Qualifier) a value of "09" (HCPCS), which qualifies the codesubmitted in field 407-D7 (Product/Service ID) as a procedure code. In field 407- D7(Product/Service ID), enter the Procedure code from Table 2 below for the appropriatevaccine administration. For example, submit the claim line with the Procedure code“0001A” (Immunization Administration). Do not submit another claim line for thevaccine procedure code as the vaccine is being provided free of charge. Pharmacieswill bill with a quantity of “1” and a day supply of “1”.NOTE: Authorized pharmacy personnel may provide the COVID-19 vaccine to persons agesthree and older in accordance with the PREP Act.NCPDP D.0 Claim Segment Field436-E1 (Product/Service ID Qualifier)407-D7 (Product/Service ID)ValueValue of "09" which qualifies the code submitted infield 407-D7 (Product/Service ID) as aprocedure codeEnter an applicable procedure code listed in Table 2442-E7 (Quantity Dispensed)Enter the value of “1” for the procedure administrationcode in Table 2405-D5 (Day Supply)Enter the value of “1”NCPDP D.0 Companion guide can be found at: ex.aspxTable 2CPTCode0001A0002AManufacturer & COVID-19 VaccineAdministration CPT Code – ShortDescriptionPfizer-BioNTech - ADM SARSCOV230MCG/0.3ML - 1st DosePfizer-BioNTech - ADM SARSCOV230MCG/0.3ML - 2nd DoseFeeEffective forDates ofServiceFeeEffectivefor Datesof Serviceon or After 13.2312/11/2020 to3/31/2021 40.004/1/2021 13.2312/11/2020 to3/31/2021 40.004/1/20210003APfizer-BioNTech - ADM SARSCOV230MCG/0.3ML -3rd DoseN/A8/12/2021* 40.008/12/20210004APfizer-BioNTech - ADM SARSCOV230MCG/0.3ML – Booster DoseN/A9/22/2021 40.009/22/2021 13.2312/18/2020 to3/31/2021 40.004/1/2021 13.2312/18/2020 to3/31/2021 40.004/1/20210011A0012AModerna - ADM SARSCOV2100MCG/0.5ML - 1st DoseModerna - ADM SARSCOV2100MCG/0.5ML - 2nd Dose
0013AModerna - ADM SARSCOV2100MCG/0.5ML – 3rd DoseN/A8/12/2021* 40.008/12/20210064AModerna – ADM SARSCOV250MCG/0.25ML – Booster DoseN/A10/20/2021 40.0010/20/20210094AModerna – ADM SARSCOV250MCG/0.5 ML – Booster DoseN/A3/29/2022 40.003/29/2022 13.232/27/2021 to3/31/2021 40.004/1/2021N/A10/20/2021 40.0010/20/20210031A0034AJanssen - ADM SARSCOV2 VACAD26 .5MLJanssen - ADM SARSCOV2 VACAD26 .5ML - Booster Dose0051APfizer-BioNTech – ADM SARSCV230MCG TRS-SUCR – 1st DoseN/A1/3/2022 40.001/3/20220052APfizer-BioNTech – ADM SARSCV230MCG TRS-SUCR – 2nd DoseN/A1/3/2022 40.001/3/20220053APfizer-BioNTech – ADM SARSCV230MCG TRS-SUCR – 3rd DoseN/A1/3/2022 40.001/3/20220054APfizer-BioNTech – ADM SARSCV230MCG TRS-SUCR – Booster DoseN/A1/3/2022 40.001/3/20220071APfizer-BioNTech - ADM SARSCOV210MCG/0.2ML Trs-Sucr (ages 5-11)1st DoseN/A11/3/2021 40.0011/3/2021N/A11/3/2021 40.0011/3/2021N/A1/3/2022 40.001/3/2022N/A5/17/2022 40.00 5/17/2022N/A6/17/2022 40.00 6/17/2022N/A6/17/2022 40.00 6/17/2022N/A6/17/2022 40.00 6/17/2022N/A6/17/2022 40.00 6/17/2022N/A6/17/2022 40.00 fizer-BioNTech - ADM SARSCOV210MCG/0.2ML Trs-Sucr (ages 5-11)2nd DosePfizer-BioNTech - ADM SARSCOV210MCG/0.2ML Trs-Sucr (ages 5-11)3rd DosePfizer-BioNTech - ADM SARSCOV210MCG/0.2ML Trs-Sucr (ages 5-11)Booster DosePfizer-BioNTech - ADM SARSCOV23MCG/0.2ML Trs-Sucr (6mos – 4yrs)1st doseIPfizer-BioNTech - ADM SARSCOV23MCG/0.2ML Trs-Sucr (6mos – 4yrs)2nd doseIPfizer-BioNTech - ADM SARSCOV23MCG/0.2ML Trs-Sucr (6mos – 4yrs)3rd doseIModerna - ADM SARSCOV2L25MCG/0.25ML (6mos – 5yrs) – 1stDoseIModerna - ADM SARSCOV2L25MCG/0.25ML (6mos – 5yrs) – 2ndDoseI
NOTE: Pharmacy claims for dates of service on or after April 1, 2021, that were submittedprior to June 1, 2021, and were paid 13.23 will be automatically reprocessed by eMedNYand will pay the 40.00 administration fee. Providers do not need to submit claimadjustments. * If a claim was denied for the administration of a 3rd dose prior to 8/23/2021,the pharmacy will need to re-submit the claim for reimbursement.2. Please see the July 2020 Medicaid Update for further guidance on origin codeand serial number values that must be submitted on the claim. In the origincode use “5” and the corresponding serial number of “99999999” for“Pharmacy dispensing” when applicable for non-patient specific orders.NCPDP D.0 ClaimSegment Field444-E9 (Pharmacist ID)411-DB (Prescriber ID)ValueEnter Pharmacist NPI numberPlease leave field blankUpdates to procedure codes will be available PDFS/Pharmacy Fee Schedule.x ls.C. Qualified Other Rate-Based ProvidersThe following billing instructions and fees apply to Medicaid FFS.1. The provider types listed below may bill Medicaid FFS and MMC plans foradministration of authorized COVID-19 vaccine when administered by provideror facility staff to Medicaid members in a residential or other institutional setting.2. The administration fee is in addition to the rate (i.e., per diem, per visit, perhour) reimbursed to the provider and must be billed to Medicaid separately.3. Rate-based providers may also bill for COVID-19 vaccine administration ona stand-alone claim when other services are not provided.4. The providers identified below have been enrolled under COS 0268 and willbe issued the rate codes identified in Table 3 below for billing purposes: Skilled Nursing Facilities (SNFs) Certified Home Health Agencies (CHHAs) Hospice Adult Day Health Care (ADHC) Inpatient Hospitals Voluntary Foster Care Agencies (VFCAs) Assisted Living Programs (ALPs)5. Rate-based providers administering a COVID-19 vaccine to Medicaidmembers with Family Planning only coverage should bill a separate claim forCOVID-19 vaccine administration using the appropriate rate code representingthe COVID-19 vaccine administered from Table 3 with ICD-10 diagnosis code
Z23 (encounter for immunization) as the primary diagnosis on the claim andthe appropriate COVID-19 vaccine administration CPT code representing theCOVID-19 vaccine administered from Table 2.Table 3RateCode5497549855085514549955005509Rate Code DescriptionPFIZER - COVID-19 VaccineAdministration – 1st DosePFIZER - COVID-19 VaccineAdministration – 2nd DosePFIZER - COVID-19 VaccineAdministration – 3rd DosePFIZER - COVID-19 VaccineAdministration – Booster DoseMODERNA - COVID-19 VaccineAdministration – 1st DoseMODERNA - COVID-19 VaccineAdministration – 2nd DoseMODERNA - ADM SARSCOV2100MCG/0.5ML – 3rd DoseFeeEffectivefor Dates ofService:FeeEffectivefor Datesof Serviceon or After 13.2312/11/2020to 3/31/2021 40.004/1/2021 13.2312/11/2020to 3/31/2021 40.004/1/2021N/A8/12/2021 40.008/12/2021N/A9/22/2021 40.009/22/2021 13.2312/18/2020to 3/31/2021 40.004/1/2021 13.2312/18/2020to 3/31/2021 40.004/1/2021N/A8/12/2021 40.008/12/20215515MODERNA – ADM SARSCOV250MCG/0.25ML – Booster DoseN/A10/20/2021 40.0010/20/20216118Moderna – ADM SARSCOV250MCG/0.5 ML – Booster DoseN/A3/29/2022 40.003/29/20225507JANSSEN - COVID-19 VaccineAdministration 13.232/27/2021 to3/31/2021 40.004/1/20215519JANSSEN - COVID-19 VaccineAdministration – Booster DoseN/A10/20/2021 40.0010/20/20215510PFIZER - COVID VAC (TRS-SUC)DOSE 1 - 0051AN/A1/3/2022 40.001/3/20225511PFIZER - COVID VAC (TRS-SUC)DOSE 2 - 0052AN/A1/3/2022 40.005512PFIZER - COVID VAC (TRS-SUC)DOSE 3 - 0053AN/A1/3/2022 40.001/3/20225513PFIZER - COVID VAC (TRS-SUC)BOOSTER - 0054A1/3/2022 40.001/3/2022N/A1/3/2022
5516Pfizer-BioNTech - ADMSARSCOV2 10MCG/0.2ML Trs-Sucr(ages 5-11) 1st Dose – 0071AN/A11/3/2021 40.0011/3/20215517Pfizer-BioNTech - ADMSARSCOV2 10MCG/0.2ML Trs-Sucr(ages 5-11) 2nd Dose – 0072AN/A11/3/2021 40.0011/3/20215540Pfizer-BioNTech - ADMSARSCOV2 10MCG/0.2ML Trs-Sucr(ages 5-11) 3rd Dose – 0073AN/A1/3/2022 40.001/3/2022N/A5/17/2022 40.005/17/2022N/A6/17/2022 40.006/17/2022N/A6/17/2022 40.006/17/2022N/A6/17/2022 40.006/17/2022N/A6/17/2022 40.006/17/2022N/A6/17/2022 NTech - ADMSARSCOV2 10MCG/0.2ML Trs-Sucr(ages 5-11) Booster Dose – 0074APfizer-BioNTech - ADMISARSCOV2 3MCG/0.2ML Trs-Sucr(6mos – 4yrs) 1st dose – 0081AiPfizer-BioNTech - ADMISARSCOV2 3MCG/0.2ML Trs-Sucr(6mos – 4yrs) 2nd dose – 0082AiPfizer-BioNTech - ADMISARSCOV2 3MCG/0.2ML Trs-Sucr(6mos – 4yrs) 3rd dose – 0083AiModerna - ADM SARSCOV225MCG/0.25ML (6mos – 5yrs) – 1stDose – 0111AIModerna - ADM SARSCOV225MCG/0.25ML (6mos – 5yrs) – 2ndDose – 0112AInNOTE: Rate-based claims for dates of service on or after April 1, 2021 will beautomatically adjusted to reflect the new 40.00 administration fee. Providers will nothave to take any further action.*Rate Code activation letters were sent to rate-based providers for rate codes 5559 and 5560 withinaccurate descriptions identifying incorrect age parameters for these COVID-19 vaccineadministration rate codes. The correct descriptions for rate codes 5559 and 5560 are listed abovein table 3.III. Medicaid Managed CareA. MMC Coverage PolicyThe Medicaid coverage policy in Section I above applies to all types of MMC Plans.B. MMC ReimbursementThe COVID-19 vaccine administration billing instructions in Section II above are
specific to Medicaid FFS. For individuals enrolled in MMC, providers should checkwith the individual’s MMC Plan for implementation details and billing instructions.1. Effective April 1, 2021, MMC Plans will reimburse providers no less than theMedicaid FFS rate for COVID-19 vaccine administration.2. MMC Plans must cover the cost of vaccine administration by qualifiedproviders who do not participate in the MMC Plan’s network.3. Rate-based and office-based provider reimbursement for the vaccineadministration must be made separately from visit reimbursement, as detailedin Section II.Additional Resources:COVID-19 Vaccine Information for Providers: information-providersAdditional COVID-19 Guidance for NYS Medicaid Providers:https://www.health.ny.gov/health care/medicaid/covid19/NYS Medicaid vaccine policy and billing guidance (Non-COVID-19 related):https://www.health.ny.gov/health care/medicaid/program/update/2020/no12 2020- 07.htm#vaccinationPharmacist as Immunizer Fact Sheet for NY Medicaid’s policy and billing forother vaccines:https://www.health.ny.gov/health care/medicaid/program/phar immun fact.htm.CDC information on COVID-19: eekly Healthcare Provider COVID-19 alth-providerwebinarQuestions:Medicaid FFS coverage and policy questions should be directed to the Office ofHealth Insurance Programs, Division of Program Development and Management, at(518) 473–2160 or FFSMedicaidPolicy@health.ny.gov.MMC reimbursement, billing, and/or documentation requirement questions shouldbe directed to the enrollee's MMC plan.Medicaid FFS claim questions should be directed to the eMedNY Call Center at
(800) 343–9000.Medicaid FFS Pharmacy Policy questions should be directed to (518) 486-3209 orppno@health.ny.gov.
3. Office-based practitioners should bill a professional claim for COVID-19 vaccine administration. 4. The COVID-19 vaccine administration CPT codes above include the actual work of administering the vaccine, including all necessary counseling provided to patients and/or caregivers for the dose administered, required vaccination
