Medicare Part B Billing for the COVID-19 Vaccine and Monoclonal Antibody

Medicare Billing for COVID-19 Vaccine Shot Administration

How to Bill for COVID-19 Shot Administration

• You’ll be able to bill on single claims for the COVID-19 vaccine administration, or submit claims on a roster bill for multiple patients at one time.
• When COVID-19 vaccine doses are provided by the government without charge, only bill for the vaccine administration. Do not include the vaccine codes on the claim when the vaccines are free.
• If the Medicare beneficiary is enrolled in a Medicare Advantage Plan, submit your COVID-19 claims to original fee-for-service Medicare. This applies to all patients enrolled in Medicare Advantage in 2020 and 2021.

Helpful definitions

• Mass Immunizers: Mass immunizers can give flu, pneumococcal, and soon to be added COVID-19 shots, to groups of individuals (like people who live in a retirement community). Mass immunizers can be a traditional provider, like a physician, or a nontraditional provider, like a drug store, public health clinic or senior center. We created the mass immunizer specialty for those providers who wouldn't otherwise be eligible for Medicare enrollment. Mass immunizers must submit all claims as roster billed professional claims.
• Roster Billing: This is a way for you to submit multiple claims for flu, pneumococcal and soon to be added COVID-19 shots. If you’re enrolled as a mass immunizer, you must use roster billing.
  • You must administer the same type of shot to five or more people on the same date of service. You must bill each type of shot on a separate roster bill. You cannot combine flu, pneumococcal and COVID-19 vaccine codes on the same roster bill.
  • It’s quick and easy to use roster billing for flu, pneumococcal and soon to be added COVID-19 shots.
• Centralized Billers: Centralized billing allows mass immunizers to send all roster bill claims for flu, pneumococcal, and soon to be added COVID-19 vaccinations to a single MAC, Novitas, for payment, regardless of where you administer them. Medicare makes geographic payment adjustments based on the locality where you administer the shot. You must submit all centralized biller claims as professional claims on a roster bill.
• Order: A communication from the treating physician/practitioner requesting a diagnostic test is performed for the patient.

How to Submit a Claim if the Medicare Beneficiary is Enrolled in a Medicare Advantage Plan

Important information: Submit all claims to original Medicare fee-for-service contractor, NOT the Medicare Advantage Plan.                                                              

National Government Services is the MAC for J6 - Illinois, Minnesota and Wisconsin, as well as JK - Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont

How to Submit Institutional claims

If you use roster billing for institutional claims, you must administer shots to at least five patients on the same date, unless the institution is an inpatient hospital. You can also submit individual claims.

What are valid types of bills for roster billing?

• 12X, Hospital Inpatient**
• 13X, Hospital Outpatient**
• 22X, SNF covered Part A stay (paid under Part B) and Inpatient Part B
• 23X, SNF Outpatient
• 34X, Home Health (Part B Only)
• 72X, Independent and Hospital-based Renal Dialysis Facility
• 75X, Comprehensive Outpatient Rehabilitation Facility
• 81X, Hospice (Non-hospital)
• 82X, Hospice (Hospital)
• 85X, Critical Access Hospital

**For hospitalized patients, Medicare pays for the COVID-19 shots separately from the DRG rate and disallows billing them on 11X.

How to Submit a Part A Institutional Claim

Electronic Claims

Use Direct Data Entry:

1. Option 02, Claims Attachment
2. Option 87, Roster Bill Entry

Paper Claims

1. CMS-1450 (UB-04)
2. Roster form for patients (contact your MAC for this form)
   

How to Submit Part B Professional Claims

If you use roster billing for professional claims, you must administer the same type of shot to five or more people on the same date of service. You can also submit individual claims.

Electronic Claims Options available:

• Utilize your current claim submission software and Network Service Vendor.
• Submit claims using our provider portal NGSConnex.com.
• Use PC-ACE billing software to submit directly to your MAC. Download this free billing software from your MAC and electronically submit professional claim roster billing.

Paper Claims

1. Health Insurance Claim Form (CMS-1500)
2. Roster form for patients

Roster Billing

Streamlined process for submitting vaccination claims for large groups of individuals.

• All patients have the same service
• Not used for single patient billing

The patient roster form includes the following with a single modified CMS-1500 claim form as roster cover document for each facility where the services are rendered:

• Patients name, address, Medicare number, date of birth and gender
• Date of service
• Beneficiary signature or stamped “Signature on File”
• Providers name and identification number
• Control number for contractor

How to Submit a Centralized Bill

Centralized Billers: Centralized billing allows mass immunizers to send all roster bill claims for flu, pneumococcal, and soon to be added COVID-19 vaccinations to a single MAC, Novitas, for payment, regardless of where you administer the shots. Medicare makes geographic payment adjustments based on the locality where you administer the shot. You must submit all centralized biller claims as professional claims on a roster bill.You must operate in at least three MAC Jurisdictions. You can refer to the Who are the MACs web page on the CMS website.

Medicare Part B Payment for COVID-19 Vaccines and Certain Monoclonal Antibodies during the Public Health Emergency

CMS has released a set of toolkits for providers, states and insurers to help the health care system prepare and assist in swiftly administering these products once they become available. These toolkits are located on CMS' COVID-19 Vaccine Policies & Guidance web page. These resources are designed to increase the number of providers that can administer the products and ensure adequate reimbursement for administration in Medicare, while making it clear to private insurers and Medicaid programs their responsibility to cover these products at no charge to beneficiaries. This webpage provides the payment allowances and other related information for these products. For more information, review the COVID-19 provider toolkit.

Payment Allowances and Effective Dates for COVID-19 Vaccines and their Administration During the Public Health Emergency

*Since we anticipate that providers, initially, will not incur a cost for the product, CMS will update the payment allowance at a later date. Providers should not bill for the product if they received it for free.

**These rates will also be geographically adjusted for many providers. For providers and suppliers with payments that are geographically adjusted by the methodology used by the Medicare Physician Fee Schedule, files with the geographically adjusted payment rates for COVID-19 vaccine administration are included in the “Additional Resources” section below. Certain settings utilize other payment methodologies, such as payment based on reasonable costs.

Payment Allowances and Effective Dates for COVID-19 Monoclonal Antibodies and Their Administration During the Public Health Emergency:

*Since we anticipate that providers, initially, will not incur a cost for the product, CMS will update the payment allowance at a later date.  Providers should not bill for the product if they received it for free.

*** Medicare will pay a rate of $309.60 for many providers. These rates will also be geographically adjusted for many providers. For providers and suppliers with payments that are geographically adjusted by the methodology used by the Medicare Physician Fee Schedule, files with the geographically adjusted payment rates for monoclonal antibody administration are included in the “Additional Resources” section below. Certain settings utilize other payment methodologies, such as payment based on reasonable costs.

Billing

• For billing single claims for COVID-19 vaccines and monoclonal antibodies, follow the instructions below.
• For roster billing and centralized billing refer to the Medicare Billing for COVID-19 Vaccine Shot Administration web page.
• When COVID-19 vaccine and monoclonal antibody doses are provided by the government without charge, only bill for the vaccine administration. Don't include the vaccine codes on the claim when the vaccines are free.
• If the patient is enrolled in a MA plan, submit your COVID-19 vaccine and monoclonal antibody infusion claims to Original Fee-for-Service Medicare in 2020 and 2021.

COVID-19 Vaccines and Administration

Providers can submit claims using the following claim example:

• Claim should include the proper billing of the ICD-10 in item 21:

• • Z23 - Encounter for immunization
    
  • Report the proper date of service
  • Report the proper place of service
  • Use the applicable CPT or HCPCs code:

• • • 0001A - Used for the first dose of Pfizer
    • 0002A - Used for the 2^nd dose of Pfizer

• • • 0011A Used for the first dose of Moderna
    • 0012A - Used for the 2^nd dose of Moderna

• • • 0021A Used for the first dose of AstraZeneca
    • 0022A Used for the 2nd dose of AstraZeneca

Monoclonal Antibodies and Administration

Please Note: Providers should not bill for the cost of the vaccine itself if they received it for free.

Providers can submit claims using the following claim example:

Claim should include the proper billing of the ICD-10 in item 21:

• Primary diagnosis of Z23, secondary diagnosis of U0071 as appropriate
• Report the proper date of service
• Report the proper place of service
• Use the applicable CPT or HCPCs code:

• • Q0239 - Used for the first dose of Eli Lilly
  • M0239 - Used for the second dose of Eli Lilly

• • M0243 - Used for the first dose of Regeneron
  • Q0243 - Used for the second dose of Regeneron

Provider Eligibility

Are you already enrolled in Medicare?

If you’re enrolled in Medicare under these institutional or noninstitutional provider types, you don’t need to take any action to administer and bill the COVID-19 shot, either through individual claims or roster bill, without enrolling as a mass immunizer.

If you’re not enrolled or enrolled under these institutional or non-institutional provider type that do not allow you to bill for administering vaccines, enroll as a mass immunizer.

If You're Not Enrolled or Action is Needed

Hotline for Temporary Enrollment

Mass Immunizer enrolling over the phone is quick and easy.

• NGS Provider Enrollment COVID-19 Toll Free Temporary Enrollment Hotline 888-802-3898

• • Must qualify as a mass immunizer or other Medicare provider type that allows billing for administering vaccines and provide the following information:

• • • LBN
    • NPI
    • TIN
    • Practice location and state license, if applicable.

• After established, to be a permanent enrollment, send in CMS forms at least 30 days after the lifting of the COVID-19 PHE waiver.

Important:  If NGS is not your MAC, CMS has a list of each MACs enrollment hotline number, state and territory on the COVID-19 MAC Webpages and Hotlines PDF.

Mass Immunizers Can Enroll as a Centralized Biller

• Mass immunizers can roster bill Novitas with a single enrollment regardless of the geographic location.
• You must operate in at least three MAC Jurisdictions and get prior approval from Novitas to centralize bill.

Contact Novitas: 855-247-8428

Additional Resources

• NGS COVID-19 web page is available via our website banner

• CMS Enrollment for Administering COVID-19 Vaccine Shots
• CMS COVID-19 provider toolkit 
• CDC COVID-19 vaccination communication toolkit for medical centers, clinics, and clinicians 
• FDA COVID-19 vaccines webpage 
• Medicare Learning Network® –MLN Connects Special Edition Articles
  • 12/14/2020 Special Edition COVID-19 Vaccine Codes: Updated Effective Date for Pfizer-BioNtech
  • 12/22/2020 Special Edition COVID-19 Vaccine Codes: Updated Effective Date for Moderna

Billing Frequently Asked Questions

• CMS COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing

CMS Coronavirus (COVID-19) Current Emergencies, Waivers and Flexibilities Resources

• Current Emergencies
• Waivers and Flexibilities

Posted 1/12/2021