Resources
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.
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How to get Paid for COVID-19 Vaccines and Monoclonal Antibodies
Table of Contents
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.
Managing the administrative and clinical processes connected with claim processing, payment, and revenue generation is healthcare revenue cycle management (HRCM). A patient service revenue collection process comprises the identification, management, and collection of revenue from patient services.
The financial process is critical in ensuring that healthcare organizations can continue to provide treatment to their patients. Healthcare revenue cycle management (HRCM) is used by facilities to collect earnings and, as a result, keep spending under control.
PAYMENT ALLOWANCES AND EFFECTIVE DATES FOR COVID-19 VACCINES AND THEIR ADMINISTRATION DURING THE PUBLIC HEALTH EMERGENCY: (DOS = DATE OF SERVICE, TBD = TO BE DETERMINED)
| CPT Code | CPT Short Descriptor | Labeler Name | Vaccine/Procedure Name | National Payment Allowance Effective for Claims with DOS on or after 03/15/2021 | National Payment Allowance Effective for Claims with DOS through 03/14/2021 | Effective Dates |
|---|---|---|---|---|---|---|
| 91300 | SARSCOV2 VAC 30MCG/0.3ML IM | Pfizer | Pfizer-Biontech Covid-19 Vaccine | $0.010[1] | $0.010[1] | 12/11/2020 – TBD |
| 0001A | ADM SARSCOV2 30MCG/0.3ML 1ST | Pfizer | Pfizer-Biontech Covid-19 Vaccine Administration – First Dose | $40.000[2] | $16.940[2] | 12/11/2020 – TBD |
| 0002A | ADM SARSCOV2 30MCG/0.3ML 2ND | Pfizer | Pfizer-Biontech Covid-19 Vaccine Administration – Second Dose | $40.000[2] | $28.390[2] | 12/11/2020 – TBD |
| 91301 | SARSCOV2 VAC 100MCG/0.5ML IM | Moderna | Moderna Covid-19 Vaccine | $0.010[1] | $0.010[1] | 12/18/2020 – TBD |
| 0011A | ADM SARSCOV2 100MCG/0.5ML1ST | Moderna | Moderna Covid-19 Vaccine Administration – First Dose | $40.000[2] | $16.940[2] | 12/18/2020 – TBD |
| 0012A | ADM SARSCOV2 100MCG/0.5ML2ND | Moderna | Moderna Covid-19 Vaccine Administration – Second Dose | $40.000[2] | $28.390[2] | 12/18/2020 – TBD |
| 91302 | SARSCOV2 VAC 5X10^10VP/.5MLIM | AstraZeneca | AstraZeneca Covid-19 Vaccine | $0.010[1] | Code not active during this time | xx/xx/xxxx – TBD |
| 0021A | ADM SARSCOV2 5X10^10VP/.5ML 1 | AstraZeneca | AstraZeneca Covid-19 Vaccine Administration – First Dose | $40.000[2] | Code not active during this time | xx/xx/xxxx – TBD |
| 0022A | ADM SARSCOV2 5X10^10VP/.5ML 2 | AstraZeneca | AstraZeneca Covid-19 Vaccine Administration – Second Dose | $40.000[2] | Code not active during this time | xx/xx/xxxx – TBD |
| 91303 | SARSCOV2 VAC AD26 .5ML IM | Janssen | Janssen Covid-19 Vaccine[3]*** | $0.010[1] | $0.010[1] | 02/27/2021 – TBD |
| 0031A | ADM SARSCOV2 VAC AD26 .5ML | Janssen | Janssen Covid-19 Vaccine Administration[3]*** | $40.000[2] | $28.390[2] | 02/27/2021 – TBD |
| 91304 | SARSCOV2 VAC 5MCG/0.5ML IM | Novavax | Novavax Covid-19 Vaccine | $0.010[1] | Code not active during this time | xx/xx/xxxx – TBD |
| 0041A | ADM SARSCOV2 5MCG/0.5ML 1ST | Novavax | Novavax Covid-19 Vaccine Administration – First Dose | $40.000[2] | Code not active during this time | xx/xx/xxxx – TBD |
| 0042A | ADM SARSCOV2 5MCG/0.5ML 2ND | Novavax | Novavax Covid-19 Vaccine Administration – Second Dose | $40.000[2] | Code not active during this time | xx/xx/xxxx – TBD |
[1] 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.
[2] 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 (MPFS), 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.
[3] Johnson & Johnson COVID-19 Vaccine
PAYMENT ALLOWANCES AND EFFECTIVE DATES FOR COVID-19 MONOCLONAL ANTIBODIES AND THEIR ADMINISTRATION DURING THE PUBLIC HEALTH EMERGENCY:
| HCPCS Code | CPT Short Descriptor | Labeler Name | Vaccine/Procedure Name | National Payment Allowance Effective for Claims with DOS on or after 05/6/2021 | National Payment Allowance Effective for Claims with DOS through 05/5/2021 | Effective Dates |
|---|---|---|---|---|---|---|
| Q0239 | Bamlanivimab-xxxx | Eli Lilly | Injection, bamlanivimab, 700 mg | Code not active during this time period | $0.010[1] | 11/10/2020 – 04/16/2021[4] |
| M0239 | Bamlanivimab-xxxx infusion | Eli Lilly | Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring | Code not active during this time period | $309.600[3] | 11/10/2020 – 04/16/2021[4] |
| Q0243 | Casirivimab and imdevimab | Regeneron | Injection, casirivimab and imdevimab, 2400 mg | $0.010[1] | $0.010[1] | 11/21/2020 – TBD |
| M0243 | Casirivi and imdevi infusion | Regeneron | Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring | $450.00[3] | $309.600[3] | 11/21/2020 – TBD |
| M0244 | Casirivi and imdevi infus hm | Regeneron | Intravenous infusion, casirivimab and imdevimab 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. | $750.00[3] | Code not active during this time period | 05/06/2021 – TBD |
| Q0245 | Bamlanivimab and etesevima | Eli Lilly | Injection, bamlanivimab and etesevimab, 2100 mg | $0.010[1] | $0.010[1] | 02/09/2021 – TBD |
| M0245 | Bamlan and etesev infusion | Eli Lilly | intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring | $450.00[3] | $309.600[3] | 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. | $750.00[3] | Code not active during this time period | 05/06/2021 – TBD |
[1] 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.
[3] These rates will 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 (MPFS), 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.
[4] On April 16, 2021, the FDA revoked the EUA that allowed for the investigational monoclonal antibody therapy bamlanivimab, when administered alone, to be used for the treatment of mild-to-moderate COVID-19 in adults and certain pediatric patients. Due to this revocation, Medicare will not pay for claims with HCPCS codes M0239 or Q0239 with dates of service after 4/16/2021.
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