Medical Coding Rights

Guidelines for COVID-19 vaccines and monoclonal antibodies Billing The patient can get the vaccines including of booster dose and or additional doses. The patient administered the vaccine with no out of pocket cost for both vaccines and administration of the vaccines. Vaccinate everyone, including the uninsured, regardless of coverage or network status. 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 Medicare Advantage (MA) plan, submit your COVID-19 vaccine and monoclonal antibody infusion claims to Original Medicare in 2020 and 2021. On or after January 1, 2022, claims for vaccine or mAb administrations for Medicare Advantage enrollees should be submitted to the Medicare Advantage plan.  For services provided to Medicare Advantage enrollees on or after January 1, 2022, contact the Medi

CPT Code CPT Code Description  86318 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg, reagent strip); 86328 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) 86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen 86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer 86413 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) 87301 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked

Flu & Pneumococcal Vaccines Updates for September 2021 Flu & Pneumococcal Vaccines are Expanded SNF Enforcement Discretion for Certain Pharmacy Billing effective from 09/20/2021. CMS exercised enforcement discretion for Skilled Nursing Facility (SNF) consolidated billing provisions related to flu and pneumococcal vaccines.  This allows Medicare-enrolled immunizers, including pharmacies, to bill directly and get direct reimbursement from the Medicare program (including vaccine administration and product), whether these vaccines are administered at the same time (co-administered) with a COVID-19 vaccine or at different times.  COVID-19 National Public Health Emergency Extension The U.S. Department of Health and Human Services has extended the COVID-19 national public health emergency by another 90 days.  And it was scheduled to end Oct. 17, 2021 and now it has been scheduled through Jan. 15, 2022. The extension is applicable for following services, Cost share waivers – Testing Co

Third Dose of Moderna COVID-19 vaccine CPT code has been released, 0013A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose Other  administration codes are,  0011A -   Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose 0012A -  Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose Vaccine CPT Code 91301-  Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, pr

Coverage without cost-sharing available for eligible people with Medicare, Medicaid, CHIP, and Most Commercial Health Insurance Coverage Following the FDA’s recent action that authorized a booster dose of the Pfizer COVID-19 vaccine for certain high-risk populations and a recommendation from the CDC, CMS will continue to provide coverage for this critical protection from the virus, including booster doses, without cost sharing. Beneficiaries with Medicare pay nothing for COVID-19 vaccines or their administration, and there is no applicable copayment, coinsurance, or deductible.  In addition, thanks to the American Rescue Plan Act of 2021, nearly all Medicaid and CHIP beneficiaries must receive coverage of COVID-19 vaccines and their administration, without cost-sharing. COVID-19 vaccines and their administration, including boosters, will also be covered without cost-sharing for eligible consumers of most issuers of health insurance in the commercial market.  CMS continues to explore wa

 Immunization Administration  0001A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; first dose. 0002A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; second dose. 0003A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; third dose. 0004A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19])

The overall will protect patients of the 50,000 providers and over 17 million health care workers in Medicare and Medicaid certified facilities for COVID-19 Vaccines. The Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), announced that emergency regulations requiring vaccinations for nursing home workers will be expanded to include, Hospitals,  Dialysis facilities,  Ambulatory surgical settings,  Home health agencies. Nursing homes with an overall staff vaccination rate of 75% or lower experience higher rates of preventable COVID infection.  In CMS’s review of available data, the agency is seeing lower staff vaccination rates among hospital and End Stage Renal Disease (ESRD) facilities.  To combat this issue, CMS is using its authority to establish vaccine requirements for all providers and suppliers that participate in the Medicare and Medicaid programs.  Vaccinations have proven to reduce the risk of severe

PROVIDER RECEIVE THE INCREASED PAYMENTS UPTO 5 TIMES As part of the Biden-Harris Administration’s ongoing commitment to increasing access to vaccinations and improving health equity, CMS is expanding opportunities for people to receive COVID-19 vaccinations in their homes.  To ensure Medicare beneficiaries who have difficulty leaving their homes or are otherwise hard-to-reach can receive the vaccination, health care providers can now receive additional payments for administering vaccines to multiple residents in one home setting or communal setting of a home.   This announcement aims to further boost the administration of COVID-19 vaccination – including second and third doses – in smaller group homes, assisted living facilities, and other group living situations. The allowing vaccine providers to receive the increased payment up to 5 times when fewer than 10 Medicare beneficiaries get the vaccine on the same day in the same home or communal setting. 

AAP - Repayment Process CMS issued payments to providers and suppliers to help ease financial strain due to a disruption in claims submission and/or claims processing related to the COVID-19 public health emergency. The Congress amended repayment process for the accelerated and advance payments through the Continuing Appropriations Act, 2021 and Other Extensions Act: Repayment will now begin one year after the date of the issuance of the payment. During the first 11 months after repayment begins, repayment will occur through automatic recoupment of 25% of Medicare payments otherwise owed to you. During the succeeding six months, repayment will occur through an automatic recoupment of 50% of Medicare payments otherwise owed to you. If AAP payment is not completed within 29 months, t he provider will receive a demand letter requiring repayment of any outstanding balance with an i nterest rate of 4%. 

COVID-19 Vaccine Additional Dose - Payment Medicare stands ready to pay for administering an additional dose of COVID-19 vaccine consistent with the FDA emergency use authorization (EUA).  They will pay the same amount to administer this additional dose as we did for other doses of the COVID-19 vaccine ( approximately $40 each) .  The U.S. Food and Drug Administration amended the emergency use authorizations (EUAs) for both the Pfizer-BioNTech COVID-19 Vaccine and the Moderna COVID-19 Vaccine to allow for the use of an additional dose in certain immunocompromised individuals, specifically, solid organ transplant recipients or those who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise. Additional New CPT codes - COVID-19 Vaccine - Effective from 08/12/2021 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 c

Temporary cost-share waivers extended to Oct. 17, 2021 The national public health emergency has been extended from July 19, 2021, to Oct. 17, 2021. Below is an overview of how that extension affects temporary provisions for COVID-19 testing and testing-related visits. Individual Exchange, Individual and Group Market health plans:  From Feb. 4, 2020, through the national public health emergency period, UnitedHealthcare is waiving cost-sharing for in-network and out-of-network COVID-19 tests and testing-related visits. Medicare Advantage:  From Feb. 4, 2020, through the national public health emergency period, UnitedHealthcare is waiving cost-sharing for in-network and out-of-network tests for COVID-19, including testing-related telehealth visits. Medicaid:  State-specific rules and other state regulations may apply. For Medicaid and other state-specific regulations, please refer to your state-specific website or your state’s UnitedHealthcare Community Plan website. 

In March 2020 the Novel Coronavirus Disease, COVID-19, was declared a pandemic by the World Health Organization. The Centers for Disease Control (CDC), under the National Emergencies Act Section 201 and 301, is announcing further additions to the ICD-10-CM Classification related to COVID-19, which will become effective January 1, 2021. As a result of the ongoing COVID-19 public health emergency, the Centers for Disease Control and\ Prevention’s National Center for Health Statistics (CDC/NCHS) is implementing additional codes into ICD-10-CM for reporting to include, Encounter for screening for COVID-19  - Z11.52 Contact with and (suspected) exposure to COVID-19 - Z20.822 Personal history of COVID-19 - Z86.16 Multisystem inflammatory syndrome (MIS) - M35.81 Other specified systemic involvement of connective tissue - M35.89 Pneumonia due to coronavirus disease 2019 - J12.82 COVID-19 Positive - U07.1 These new codes will be effective January 1, 2021, to identify conditions resulting from C

The FDA is recommended to use "Pfizer-BioNTech" COVID-19 vaccine for adolescents aged 12-15 years.   On May 12, 2021, the Advisory Committee on Immunization Practices (ACIP) recommended the use of the "Pfizer-BioNTech" COVID-19 vaccine in adolescents aged 12-15 years, and CDC Director Rochelle Walensky adopted this ACIP recommendation. All COVID-19 vaccination providers are directed and required to make available and administer COVID-19 vaccine to all persons eligible to receive the COVID-19 vaccine consistent with the applicable Emergency Use Authorizations for such products.     The COVID-19 vaccines themselves are free to everyone 12 years and older in the United States, but providers incur costs associated with administering them, training staff, and storing the vaccine.  If these services are not covered by a patient’s health plan or only partially covered, providers are not allowed to balance bill the patients. Claims for reimbursement will be priced as desc

The Biden-Harris Administration is providing free access to COVID-19 vaccines for every adult living in the United States.  Accordingly, the Health Resources and Services Administration’s (HRSA) COVID-19 Coverage Assistance Fund (CAF) will cover the costs of administering COVID-19 vaccines to patients whose health insurance doesn’t cover vaccine administration fees, or does but typically has patient cost-sharing.  While patients cannot be billed directly for the COVID-19 vaccine fees, costs to health care providers on the front lines for administering COVID-19 vaccines to underinsured patients will now be fully covered through CAF, subject to available funding.  As vaccination efforts accelerate, patients will increasingly gain access to COVID-19 vaccines at locations near where they live with providers they trust. Providers are eligible for claims reimbursement if they have administered Food and Drug Administration (FDA) authorized COVID-19 vaccines under an Emergency Use Authorizatio

Modifier QW The Medicare and Medicaid only pay for laboratory tests performed in certified facilities, each claim for a HCPCS code that is considered a CLIA laboratory test is currently edited at the CLIA certificate level.  To be recognized as a test that can be performed in a facility having a CLIA certificate of waiver for listed below CPT codes and the modifier QW must be added . The CMS released updates for adding modifier QW for COVID-19 lab codes with effective date of service. The Medicare contractor shall permit the use of code 87636 QW for claims submitted by facilities with a valid, current CLIA certificate of waiver with dates of service on or after October 6, 2020 and effective from July 1, 2021 The Medicare contractor shall permit the use of code  87428 QW   for claims submitted by facilities with a valid, current CLIA certificate of waiver with   dates of service on or after November 10, 2020. The Medicare contractor shall permit the use of code  87811 QW  for claims s

The national public health emergency has been extended from April 20, 2021, to July 19, 2021. Below is an overview of how that extension affects temporary provisions for COVID-19 testing and testing-related services for major payers UHC Individual Exchange, Individual and Group Market health plans: From Feb. 4, 2020 through the national public health emergency period, UnitedHealthcare is waiving cost sharing for in-network and out-of-network COVID-19 tests and testing-related services, including testing-related telehealth visits. Medicare Advantage: From Feb. 4, 2020 through the national public health emergency period, UnitedHealthcare is waiving cost sharing for in-network and out-of-network tests for COVID-19. Medicaid : State-specific rules and other state regulations may apply. For Medicaid and other state-specific regulations, please refer to your state-specific website or your state’s UnitedHealthcare Community Plan website, if applicable. Aetna Aetna’s liberalized coverage of Co

All Medicare providers and suppliers who requested and received CAAPs that we began recovering those payments as early as March 30, 2021, depending upon the 1 year anniversary of when you received your first payment.  It also gives information on how to identify recovered payments.  Title V (Section 2501) of the Continuing Appropriations Act, 2021 and Other Extensions Act, enacted on October 1, 2020, amended the CAAP repayment terms for all providers and suppliers who requested and received CAAPs during the COVID-19 PHE and established a lower interest rate of 4% for any demanded overpayments to recover CAAP balances due.  The CAAP repayment terms provide as follows, Repayment begins 1 year starting from the date we issued your first CAAP. Beginning 1 year from the date we issued the CAAP and continuing for 11 months, we’ll recover the CAAP from Medicare payments due to providers and suppliers at a rate of 25%. After the end of this 11 month period, we’ll continue to recover the remain

The AMA released on Jan 19, 2021,  A fourth COVID-19 vaccine code has been released by the American Medical Association, along with an administration code.   91303 - Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, for intramuscular use 0031A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative-free, 5x1010 viral particles/0.5mL dosage, single dose The Janssen COVID-19 vaccine EUA/approval, providers will report 0031A for the administration of vaccine 91303 Note that Janssen is a single-dose vaccine, requiring a single administration. Providers will not have any reason to report 0031A more than once for a patient in any given year.  The AMA has also rel