Medicare Billing for COVID-19 Vaccine Shot Administration

There’s No Out-of-Pocket Cost for Your Patients

Patients can get the COVID-19 vaccine without a physician’s order or supervision, and they pay nothing for the vaccine and its administration. If you participate in the CDC COVID-19 Vaccination Program, you must:

  • Administer the vaccine with no out-of-pocket cost to your patients for the vaccine or administration of the vaccine
  • Vaccinate everyone, including the uninsured, regardless of coverage or network status

You also can’t:

  • Balance bill for COVID-19 vaccinations
  • Charge your patients for an office visit or other fee if COVID-19 vaccination is the only medical service given
  • Require additional medical or other services during the visit as a condition for getting a COVID-19 vaccination

Report any potential violations of these requirements to the HHS Office of the Inspector General:

How Do I Bill for Administering COVID-19 Vaccines?

  • You must be a Medicare-enrolled provider to bill Medicare for administering COVID-19 vaccines to Medicare patients. Learn more about Enrollment for Administering COVID-19 Vaccines.
  • You can bill on single claims for administering the COVID-19 vaccine, or submit claims on a roster bill for multiple patients at a time.
  • When you choose the Place of Service (POS) code for your Part B claims, carefully consider where you provided the vaccine. Roster billers should use POS code 60 regardless of your provider type, even if you’re not a mass immunization roster biller (provider specialty type 73).
  • When the government provides COVID-19 vaccines at no cost, only bill for the vaccine administration. Don’t include the vaccine codes on the claim when the vaccines are free.
    • You must administer the vaccine with no out-of-pocket cost to your patients for the vaccine or administration of the vaccine.
    • If you want to administer the vaccine for free, you don’t have to submit a claim to Medicare, Medicaid, or another insurer. But, you can’t charge your patients or ask them to submit a claim to Medicare or another insurer.
    • If you get government funding to help pay for administering the COVID-19 vaccine (like a federal or state grant), you can still submit a claim to Medicare for administering the vaccine.
  • If you have temporary billing privileges because of the public health emergency (PHE) and you have 1 National Provider Identifier (NPI) tied to multiple Provider Transaction Access Numbers (PTANs), use the taxonomy code on your claim to help you assign the correct PTAN.
  • Use the ICD-10 diagnosis code Z23 (encounter for immunization) on the claim. 
  • Until the PHE ends, you should include modifier CR on your claim only if you administer the COVID-19 vaccine at a temporary location that isn’t considered your actual practice location.

How Do I Bill for the Additional Payment for Administering the Vaccine in the Patient’s Home?

Review the infographic (PDF) on Medicare payment for COVID-19 vaccine administration in the home.

In addition to the requirements listed above, you must meet several other requirements to bill for the additional in-home payment amount for administering the COVID-19 vaccine to a Medicare patient:

  • You must use both of these:
    • The appropriate CPT code for the product- and dose-specific COVID-19 vaccine administration
    • The HCPCS Level II code M0201 for the additional payment amount for administering the COVID-19 vaccine in the home
  • You should only bill for the additional in-home payment amount if the sole purpose of the visit is to administer a COVID-19 vaccine. You shouldn’t bill for the additional amount if you provide and bill Medicare for another service in the same home on the same date.
  • You should bill for the additional payment amount only once per home per date of service. If you administer the COVID-19 vaccine to more than 1 Medicare patient in a single home on the same day, you should:
    • Bill the HCPCS Level II code (M0201) only 1 time for the additional payment rate
    • Bill for each dose administered using the appropriate CPT code for the product and dose-specific COVID-19 vaccine administration
  • If you submit roster bills for administering the COVID-19 vaccine in the home, you must submit 2 roster bills:
    • A roster bill containing the appropriate CPT code for the product- and dose-specific COVID-19 vaccine administration
    • A second roster bill containing the HCPCS Level II code (M0201) for the additional in-home payment amount
  • You may submit a single set of roster bills (one containing M0201 and another containing the appropriate CPT code) for multiple Medicare patients who get the COVID-19 vaccine in their individual units of a multi-unit living arrangement.

 

How Do I Bill for Medicare Advantage Patients?

For patients enrolled in a Medicare Advantage Plan in 2020 and 2021, submit COVID-19 vaccine administration claims to Original Medicare through your Medicare Administrative Contractor (MAC). Use your patients’ Medicare Beneficiary Identifiers (MBIs) (not their Medicare Advantage Plan Member IDs) to bill Original Medicare.

  • Ask your Medicare Advantage patients for their Original Medicare card. All Medicare patients have a red, white, and blue Medicare card with an MBI, including those enrolled in a Medicare Advantage Plan.
  • If your patients don’t have their Original Medicare card or don’t know their MBI, use the MBI look-up tool in your MAC’s secure portal (PDF). You’ll need your patients’ first names, last names, dates of birth, and SSNs. You can look up the MBI for any Medicare patients, including those enrolled in a Medicare Advantage Plan.
  • For Part A and Home Health and Hospice (HHH) claims, include Condition Code (CC) 78.

 

How Do I Bill for Hospice Patients?

For hospice patients under Part B only, you must include the GW modifier on COVID-19 vaccine administration claims if either of these apply:

  • The vaccine isn’t related to your patient’s terminal condition
  • The attending physician administered the vaccine

 

Billing for RHCs & FQHCs

For Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs), Medicare pays for administering COVID-19 vaccines at 100% of reasonable cost through the cost report. RHCs and FQHCs should also use the cost report to bill for administering COVID-19 vaccines to patients enrolled in a Medicare Advantage Plan. 
 

Coordination of Benefits & Medicare as Secondary Payer

Before you submit a Medicare claim for administering COVID-19 vaccines, you must find out if:

  • Your Medicare patients have other insurance, such as employer health insurance or coverage through a spouse’s employer health insurance
  • Medicare pays first or second

You must gather information both from patients with Original Medicare and those enrolled in Medicare Advantage plans. Verify the insurance information:

Medicare & Other Types of Insurance coverage

 

What if My Patients Don’t Have Medicare?

  • If you have questions about billing or payment for administering the vaccine to patients with private insurance or Medicaid, contact the health plan or state Medicaid agency
  • Patients without health insurance can also get the COVID-19 vaccine and administration at no cost. If you vaccinate these patients, you can request payment for administering the vaccine through the HRSA COVID-19 Uninsured Program.
  • Providers administering the vaccine to underinsured individuals can request reimbursement for the administration of the COVID-19 vaccine through the HRSA COVID-19 Coverage Assistance Fund for people in these situations:
    • Their health insurance doesn’t include the COVID-19 vaccine administration fees as a covered benefit
    • Their health insurance covers the COVID-19 vaccine administration but with cost sharing
       

How to Submit Institutional Claims

You may use roster billing format, or submit individual claims. CMS systems will accept roster bills for 1 or more patients that get the same type of shot on the same date of service.

What Are Valid Types of Bills for Roster Billing?

  • 12X, Hospital Inpatient**
  • 13X, Hospital Outpatient**
  • 22X, Skilled Nursing Facility (SNF)-covered Part A stay (paid under Part B) & 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 vaccines separately from the Diagnosis-Related Group (DRG) rate and doesn't allow billing them on 11X.

***If you’re a Medicare Advantage Plan provider, include Condition Code (CC) 78.

 

How Do I Submit an 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 bill for patients (find your MAC website for the roster bill)

 

How to Submit Professional Claims

You may use roster billing format or submit individual claims using the CMS-1500 form (PDF) or the 837P electronic format. CMS systems will accept roster bills for 1 or more patients that get the same type of shot on the same date of service.

How Do I submit a Professional Claim?

Electronic Claims

Download and use free PC-ACE billing software (PDF) to electronically submit professional claim roster billing directly to your MAC.

Paper Claims

  1. Health Insurance Claim Form (CMS-1500) (PDF)
  2. Roster bill for patients (find your MAC website for the roster bills)

 

What if I’m a Mass Immunizer?

Mass immunizers may use a roster bill or submit a traditional claim form, such as a CMS-1500 form (PDF) or the 837P electronic format. CMS systems will accept roster bills for 1 or more patients that get the same type of shot on the same date of service. 
 

How to Submit a Centralized Bill

Providers enrolled as centralized billers can submit a professional claim to Novitas, regardless of where you administered the vaccines.

You must operate in at least 3 MAC jurisdictions.

Page Last Modified:
06/17/2021 01:04 PM