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HOW TO GET PAID FOR COVID-19 VACCINES AND MONOCLONAL ANTIBODIES

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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.
COVID-19-Vaccines-and-Monoclonal-Antibodies

How to get Paid for COVID-19 Vaccines and Monoclonal Antibodies

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.

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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