Monoclonal Antibody COVID-19 Infusion

Review the Antiviral Resistance information in Section 15 of the authorized Fact Sheets for each monoclonal antibody therapy available under an EUA for details regarding specific variants and resistance. You should also refer to the CDC website and information from state and local health authorities regarding reports of viral variants of importance in their region to guide treatment decisions.

Review the infographic (PDF) on coverage of COVID-19 monoclonal antibody products.

COVID-19 Monoclonal Antibody Products

Following the recent statement from the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel about therapies for the COVID-19 Omicron variant, CMS created HCPCS code J0248 for VEKLURY™ (remdesivir) antiviral medication when administered in an outpatient setting. All payers can use this code, and it's effective for dates of service on or after December 23, 2021:

  • Long descriptor: Injection, remdesivir, 1 mg
  • Short descriptor: Inj, remdesivir, 1 mg

Medicare Administrative Contractors (MACs) determine Medicare coverage when there's no national coverage determination, including in cases when providers use FDA-approved drugs for indications other than what is on the approved label. The MACs consider the major drug compendia, authoritative medical literature, and accepted standards of medical practice to determine medical necessity when considering coverage. Therefore, the MACs will determine Medicare coverage for HCPCS code J0248 for VEKLURY™ (remdesivir) when you administer it in an outpatient setting. In most cases, your patient’s yearly Part B deductible and 20% co-insurance will apply when you administer remdesivir. See Average Sales Price (ASP) drug pricing files for October 2021 and January 2022.

The FDA authorized the following investigational monoclonal antibody product under emergency use authorization (EUA) for pre-exposure prophylaxis of COVID-19:

  • Tixagevimab co-packaged with cilgavimab, administered as 2 separate consecutive intramuscular injections (EUA issued December 8, 2021, latest update December 20, 2021)

The FDA authorized the use of this monoclonal antibody combination for the pre-exposure prophylaxis of COVID-19 in adults and pediatric patients (12 years and older weighing at least 40 kg) under these conditions:

  • They aren’t currently infected with SARS-CoV-2
  • They haven’t had a known recent exposure to an individual infected with SARS-CoV-2
  • One of the following apply:
    • They may not mount an adequate immune response to the COVID-19 vaccine because their immune system is moderately or severely compromised due to a medical condition or because they got immunosuppressive medications or treatments
    • They aren’t recommended to get vaccinated with any available COVID-19 vaccine, according to the approved or authorized schedule, due to a history of severe adverse reaction (for example, severe allergic reaction) to a COVID-19 vaccine

The FDA authorized the following additional investigational monoclonal antibody therapies under EUA:

  • Casirivimab and imdevimab, administered together (EUA issued November 21, 2020, latest update November 17, 2021)
  • Bamlanivimab and etesevimab, administered together (EUA issued February 9, 2021, latest update December 3, 2021)
  • Sotrovimab (EUA issued May 26, 2021, latest update December 16, 2021)
  • Tocilizumab (EUA issued June, 24 2021)

The FDA authorized the use of these monoclonal antibody therapies to treat mild-to-moderate COVID-19 in adults and pediatric patients when both of these apply:

  • The patient has a positive COVID-19 test result
  • The patient is at high risk for progressing to severe COVID-19, hospitalization, or both

Health care providers may administer these monoclonal antibody therapies only in settings where they have both of these:

  • Immediate access to medications to treat a severe infusion reaction, such as anaphylaxis
  • The ability to activate the emergency medical system (EMS)
Note:


Learn more about treatment guidelines and recommendations for using monoclonal antibody therapies.

For more information about the limits of authorized use for these monoclonal antibody therapies, including information about viral variants and antiviral resistance, review the following:

Important Update about Viral Variants

On April 16, 2021, the FDA revoked the EUA for bamlanivimab, when administered alone, due to a sustained increase in COVID-19 viral variants in the U.S. that are resistant to the solo product.

Importantly, although the FDA revoked the EUA for bamlanivimab, when administered alone, alternative monoclonal antibody therapies remain available under EUA for the same uses as previously authorized for bamlanivimab alone. The FDA indicates that alternative monoclonal antibody therapies remain appropriate to treat COVID-19 patients, and health care providers may continue using these authorized therapies:  

The FDA indicates using these other therapies may reduce the risk of treatment failure for patients infected with a COVID-19 viral variant that’s resistant to bamlanivimab when administered alone. For details about specific variants and resistance, review the Antiviral Resistance information in Section 15 of each of the Fact Sheets listed above.

To get COVID-19 monoclonal antibody therapeutics, eligible administration sites must coordinate with their respective state or territorial health department to order. Get more information on the ordering process and reporting requirements

The federal government isn't distributing Tocilizumab. You may purchase this product through typical purchasing channels.

For more information about viral variants in your area to help you make treatment decisions:

Medicare Coverage for COVID-19 Monoclonal Antibody Products

During the COVID-19 public health emergency (PHE), Medicare will cover and pay for these infusions (when furnished consistent with their respective EUAs) the same way it covers and pays for COVID-19 vaccines.

Note:
Medicare will only cover and pay for bamlanivimab (administered alone) if it was furnished, consistent with the terms of the EUA, between November 10, 2020 - April 16, 2021.


Our approach to paying for these products as COVID-19 vaccines during the PHE allows a broad range of providers and suppliers to administer these products, including but not limited to:

  • Freestanding and hospital-based infusion centers
  • Home health agencies
  • Nursing homes
  • Entities with whom nursing homes contract to administer products

To help skilled nursing facilities (SNFs) efficiently administer COVID-19 vaccines (including COVID-19 monoclonal antibody products) to residents, CMS has exercised enforcement discretion for certain statutory provisions and any associated statutory references and implementing regulations, including as interpreted in pertinent guidance (collectively, “SNF Consolidated Billing Provisions”). We allow Medicare-enrolled immunizers including, but not limited to, pharmacies working with the U.S., infusion centers, and home health agencies to bill directly and get direct payment from the Medicare Program for vaccinating Medicare SNF residents.

Health care providers administering the infusions and injections of COVID-19 monoclonal antibody products will follow the same enrollment process as those administering the COVID-19 vaccines. Get provider enrollment information.

Coding for the Administration of COVID-19 Monoclonal Antibody Products

CMS identified specific code(s) for each COVID-19 monoclonal antibody product and specific administration code(s) for Medicare payment: 

Product

EUA Effective & Revocation Date(s)

Specific Code

Administration Code

Eli Lilly and Company’s Antibody Bamlanivimab (LY-CoV555)

November 10, 2020 - April 16, 2021

Note: On April 16, 2021, the FDA revoked the EUA for bamlanivimab when administered alone.

Q0239

Long descriptor: Injection, bamlanivimab-xxxx, 700 mg

Short descriptor: Bamlanivimab-xxxx

 

M0239

Long Descriptor: Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring

Short Descriptor: Bamlanivimab-xxxx infusion

Regeneron’s Antibody casirivimab and imdevimab (REGN-COV2) (ZIP) (ZIP)

November 21, 2020 - TBD

Note: While the product EUA was originally issued on November 21, 2020, these product and administration codes are effective July 30, 2021

Q0240 (Code effective 07/30/2021 and reflects updated dosing regimen)

Long descriptor: Injection, casirivimab and imdevimab, 600 mg

Short descriptor: Casirivi and imdevi 600 mg

M0240

Long Descriptor: Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses

Short Descriptor: Casirivi and imdevi repeat

Regeneron’s Antibody casirivimab and imdevimab (REGN-COV2) (ZIP) (ZIP)

November 21, 2020 - TBD

Note: While the product EUA was originally issued on November 21, 2020, these product and administration codes are effective July 30, 2021

Q0240 (Code effective 07/30/2021 and reflects updated dosing regimen)

Long descriptor: Injection, casirivimab and imdevimab, 600 mg

Short descriptor: Casirivi and imdevi 600 mg

M0241

Long Descriptor: Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, 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, subsequent repeat doses

Short Descriptor: Casirivi and imdevi repeat hm

Regeneron’s Antibody casirivimab and imdevimab (REGN-COV2) (ZIP) (ZIP)

November 21, 2020 - TBD

 

Q0243

Long descriptor: Injection, casirivimab and imdevimab, 2400 mg

Short descriptor: Casirivimab and imdevimab

 

Q0244 (Code effective 06/03/2021 and reflects updated dosing regimen)

Long descriptor: Injection, casirivimab and imdevimab, 1200 mg

Short descriptor: Casirivi and imdevi 1200 mg

M0243

Long Descriptor: Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring

Short Descriptor: Casirivi and imdevi inj

Regeneron’s Antibody casirivimab and imdevimab (REGN-COV2) (ZIP)

November 21, 2020 – TBD
Note: While the product EUA was issued on November 21, 2020, this administration code is effective May 6, 2021   

Q0243

Long descriptor: Injection, casirivimab and imdevimab, 2400 mg

Short descriptor: Casirivimab and imdevimab

 

Q0244 (Code effective 06/03/2021 and reflects updated dosing regimen)

Long descriptor: Injection, casirivimab and imdevimab, 1200 mg

Short descriptor: Casirivi and imdevi 1200 mg

M0244

Long Descriptor: Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, 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 emergency1

Short Descriptor: Casirivi and imdevi inj hm

Eli Lilly and Company’s Antibody Bamlanivimab and Etesevimab, (ZIP)

February 9, 2021 - TBD

Q0245

Long descriptor: Injection, bamlanivimab and etesevimab, 2100 mg

Short descriptor: Bamlanivimab and etesevima

M0245

Long Descriptor: Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring

Short Descriptor: Bamlan and etesev infusion

Eli Lilly and Company’s Antibody Bamlanivimab and Etesevimab, (ZIP) 

February 9, 2021 (reissued on February 25, 2021) – TBD

Note: While the product EUA was issued on February 9, 2021, this administration code is effective May 6, 2021  

Q0245

Long Descriptor: Injection, bamlanivimab and etesevimab, 2100 mg

Short Descriptor: Bamlanivimab and etesevima

M0246

Long Descriptor: 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 emergency1

Short Descriptor:
Bamlan and etesev infus home

GlaxoSmithKline’s Antibody Sotrovimab May 26, 2021 - TBD

Q0247

Long descriptor: Injection, sotrovimab, 500 mg

Short descriptor: Sotrovimab

M0247

Long Descriptor: Intravenous infusion, sotrovimab, includes infusion and post administration monitoring

Short Descriptor: Sotrovimab infusion

GlaxoSmithKline’s Antibody Sotrovimab May 26, 2021 - TBD

Q0247

Long descriptor: Injection, sotrovimab, 500 mg

Short descriptor: Sotrovimab

M0248

Long Descriptor: Intravenous infusion, sotrovimab, 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 emergency1

Short Descriptor: Sotrovimab inf, home admin
 

Genentech’s Antibody Tocilizumab June 24, 2021 – TBD

Q02492

Long descriptor: Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg

Short descriptor: Tocilizumab for COVID-19

M0249

Long Descriptor: Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose

Short Descriptor: Adm Tocilizu COVID-19 1st 

Genentech’s Antibody Tocilizumab June 24, 2021 – TBD

Q02492

Long descriptor: Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg

Short descriptor: Tocilizumab for COVID-19

M0250

Long descriptor: Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose

Short descriptor: Adm Tocilizu COVID-19 2nd

AstraZeneca’s Antibody Tixagevimab and Cilgavimab (EVUSHELDTM) December 8, 2021 – TBD

Q0220

Long descriptor: Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 300 mg

Short descriptor: Tixagev and cilgav inj

M0220

Long descriptor: Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), includes injection and post administration monitoring

Short descriptor: Tixagev and cilgav inj
AstraZeneca’s Antibody Tixagevimab and Cilgavimab (EVUSHELDTM) December 8, 2021 – TBD

Q0220

Long descriptor: Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 300 mg

Short descriptor: Tixagev and cilgav inj

M0221

Long descriptor: Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), includes injection 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

Short descriptor: Tixagev and cilgav inj hm

 These rates don’t apply if Medicare pays you for preventive vaccines and their administration at reasonable cost (for example, federally qualified health centers, rural health clinics, and hospital-based renal dialysis facilities). 

2Given the limited clinical situations allowed under the EUA, you should only bill for tocilizumab on a 12x type of bill (TOB).

Get the most current list of billing codes, payment allowances, and effective dates.

Medicare Payment for Administering COVID-19 Monoclonal Antibody Products

To ensure immediate access during the COVID-19 PHE, Medicare covers and pays for these infusions and injections in accordance with Section 3713 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act)

CMS will continue to pay for COVID-19 monoclonal antibodies under the Medicare Part B vaccine benefit through the end of the calendar year that the PHE ends. During this interim time, we’ll maintain the administration payment amounts when you infuse or inject these products in health care settings and in the home, as described below.

Effective January 1 of the year after the year that the PHE ends:

  • CMS will pay you for COVID-19 monoclonal antibody products as biological products paid under Section 1847A of the Social Security Act
  • For administering COVID-19 monoclonal antibodies, CMS will pay you under the applicable payment system, using the appropriate coding and payment rates, similar to the way we pay for administering other complex biological products

We'll address potential refinements to payment for administering COVID-19 monoclonal antibody products through future notice-and-comment rulemaking.

Payment for Infusion

On May 6, 2021, CMS updated the Medicare payment rates for the administration of COVID-19 monoclonal antibody products. Effective for services furnished on or after May 6, 2021, the Medicare payment rate for administering COVID-19 monoclonal antibody products, authorized or approved by the FDA, is approximately $450. This rate applies to all providers and suppliers not paid reasonable cost for furnishing these products. The new rate reflects updated information about the costs involved in administering monoclonal antibody products for different types of providers and suppliers and the resources necessary to ensure providers administer the products safely and appropriately. We geographically adjusts the rate based on where you furnish the service.

Note:

Under the terms of the EUA, health care providers can only administer tocilizumab to hospitalized patients in limited clinical situations. The Medicare payment rate of approximately $450 for the administration of COVID-19 monoclonal antibody products will apply for the administration of tocilizumab when you furnish it in accordance with the EUA.


The EUA for tocilizumab also allows for 2 infusions for the same patient in limited situations. Medicare will pay approximately $450 per infusion when 2 infusions are clinically necessary. As with payments for administering other COVID-19 monoclonal antibodies, the separate Medicare payment amount of $450 per infusion of tocilizumab applies to all hospitals not paid reasonable cost for furnishing these products consistent with the EUA. CMS geographically adjusts the rate based on where you furnish the service. Get the most current geographically adjusted rates.

 

Note:
The July 30, 2021, revised EUA for casirivimab and imdevimab allows for its use for post-exposure prophylaxis (PEP) for certain patients who have been exposed to (or are at high risk of exposure to) a person with COVID-19. In these situations, use the following HCPCS codes to bill for casirivimab and imdevimab:
  • M0243 or M0244 when billing for the administration of the initial dose in a health care setting or the home
  • M0240 or M0241 when billing for the administration of any subsequent repeat doses in a health care setting or the home

The September 16, 2021, revised EUA for bamlanivimab and etesevimab allows for its use for PEP in certain adult and pediatric patients. Continue to use the same codes to bill for administering bamlanivimab and etesevimab for PEP and treatment: 

  • M0245 when billing to administer in a health care setting 
  • M0246 when billing to administer in the home or residence


Medicare also pays for treatment to address major complications:

  • As needed and appropriate
  • Consistent with existing payment methodologies for the care setting where you provide the treatment

For COVID-19 monoclonal antibody products administered before May 6, 2021, the Medicare payment rate is approximately $310.

Medicare will establish codes and rates for administering new products as the FDA approves or authorizes each product.

Get the most current list of billing codes, payment allowances, and effective dates for currently authorized monoclonal antibody products.

Payment for Infusion at Home

Beginning on May 6, 2021, Medicare established separate coding and payment for administering COVID-19 monoclonal antibody products in a patient’s home or residence. Effective for services furnished on or after May 6, 2021, the Medicare payment rate for administering COVID-19 monoclonal antibody products in a patient’s home or residence is approximately $750. This rate reflects updated information about the costs involved in furnishing these complex products in a patient’s home. For many providers and suppliers, CMS also geographically adjusts this rate based on where you furnish the service. 

Note:

These rates don’t apply if Medicare pays you for preventive vaccines and their administration at reasonable cost (for example, federally qualified health centers, rural health clinics, and hospital-based renal dialysis facilities). 


Providers and suppliers may bill for the higher home payment rate when they furnish a COVID-19 monoclonal antibody product in a “home or residence.” This includes circumstances such as a Medicare patient’s permanent residence, temporary lodging (for example, hotel or motel, hostel, or homeless shelter), and homes or residences that have been made provider-based to the hospital during the COVID-19 PHE.

If your Medicare patient’s permanent residence is a setting that provides health care services, such as an intermediate care facility, nursing facility, or skilled nursing facility, that setting would also qualify as a “home or residence” for purposes of billing codes M0241, M0244, M0246, or M0248. However, if the patient is only in that location temporarily (such as if your patient has a permanent home but is in a post-acute stay in a skilled nursing facility), the setting isn’t considered a patient’s “home or residence” for this purpose, and you shouldn’t bill for the higher “at home” HCPCS codes M0241, M0244, M0246, or M0248.

If you administer COVID-19 monoclonal antibodies to Medicare patients in traditional health care locations (for example, a hospital outpatient infusion clinic or freestanding infusion clinic), continue to bill HCPCS codes M0240, M0243, M0245, or M0247, as applicable. Inpatient locations, such as inpatient hospitals, inpatient psychiatric hospitals, long-term care hospitals, and inpatient rehabilitation hospitals, would never qualify as the “home or residence” for purposes of HCPCS codes M0241, M0244, M0246, or M0248.

Note:
Under the terms of the EUA, tocilizumab may only be infused in the hospital setting, in limited clinical situations. Providers may not furnish tocilizumab in the “home or residence,” including homes or residences that have been made provider-based to the hospital during the COVID-19 PHE. As a result, Medicare hasn’t created a separate HCPCS code for billing for the higher Medicare payment amount for administering tocilizumab in the home. 


Get the most current list of billing codes, payment allowances, and effective dates for currently authorized monoclonal antibody products.

Payment for Injection

Effective for services furnished on or after December 8, 2021, the Medicare payment rate for administering COVID-19 monoclonal antibody products through intramuscular injection for pre-exposure prophylaxis (such as tixagevimab co-packaged with cilgavimab, administered as 2 separate consecutive intramuscular injections), in select patient populations, is approximately $150.50. This rate applies to all providers and suppliers not paid reasonable cost for furnishing these products. The rate reflects information about the costs involved in administering monoclonal antibody products for different types of providers and suppliers and the resources necessary to ensure providers administer the products safely and appropriately. We geographically adjust the rate based on where you furnish the service.

Payment for Injection at Home

Effective for services furnished on or after December 8, 2021, the Medicare payment rate for administering COVID-19 monoclonal antibody products through intramuscular injection for pre-exposure prophylaxis (such as tixagevimab co-packaged with cilgavimab, administered as 2 separate consecutive intramuscular injections), in select patient populations, in a patient’s home or residence, is approximately $250.50. This rate reflects information about the costs involved in furnishing these products in a patient’s home. For many providers and suppliers, CMS also geographically adjusts this rate based on where you furnish the service.

Note:

These rates don’t apply if Medicare pays you for preventive vaccines and their administration at reasonable cost (for example, federally qualified health centers, rural health clinics, and hospital-based renal dialysis facilities). 


Providers and suppliers may bill for the higher home payment rate when they furnish a COVID-19 monoclonal antibody product in a “home or residence.” This includes circumstances such as a Medicare patient’s permanent residence, temporary lodging (for example, hotel or motel, hostel, or homeless shelter), and homes or residences that have been made provider-based to the hospital during the COVID-19 PHE.

If your Medicare patient’s permanent residence is a setting that provides health care services, such as an intermediate care facility, nursing facility, or skilled nursing facility, that setting would also qualify as a “home or residence” for purposes of billing codes M0221. However, if the patient is only in that location temporarily (such as if your patient has a permanent home but is in a post-acute stay in a skilled nursing facility), the setting isn’t considered a patient’s “home or residence” for this purpose, and you shouldn’t bill for the higher “at home” HCPCS code M0221.

If you administer these COVID-19 monoclonal antibody products in Medicare patients in traditional health care locations (for example, a hospital outpatient infusion clinic or freestanding infusion clinic), continue to bill HCPCS code M0220, as applicable. Inpatient locations, such as inpatient hospitals, inpatient psychiatric hospitals, long-term care hospitals, and inpatient rehabilitation hospitals, would never qualify as the “home or residence” for purposes of HCPCS code M0221.

Payment for Product

In response to the COVID-19 PHE, the government initially purchased the COVID-19 monoclonal antibody products and made them available for free. Medicare doesn’t pay for the COVID-19 monoclonal antibody products that providers get for free, including:

  • Casirivimab and imdevimab, to be administered together
  • Bamlanivimab and etesevimab, to be administered together
  • Sotrovimab
  • Tixagevimab co-packaged with cilgavimab, administered as 2 separate consecutive intramuscular injections

The government won’t purchase tocilizumab and make it available for free. Get the most current payment allowances and effective dates for the product.

Note:
CMS pays for tocilizumab based on the number of units administered, so you should include the total number of units administered on the claim per day. For example, if you administer 200mg of tocilizumab in 1 infusion, you should add 200 as the number of units on the claim. If you give 2 infusions in the same day, you should include the total units for both infusions with the product code Q0249 on 1 line (per day).


CMS set the payment rate for COVID-19 monoclonal antibody products the same way we set the payment rate for COVID-19 vaccines. For example, Medicare will pay 95% of AWP for COVID-19 vaccines provided in the physician office setting, and pay hospital outpatient departments at reasonable cost for COVID-19 vaccines. Because CMS considers monoclonal antibody products to treat COVID-19 to be COVID-19 vaccines, they aren’t eligible for the New COVID-19 Treatments Add-on Payment (NCTAP) under the Inpatient Prospective Payment System (IPPS).

There’s No Cost for Your Patients

There’s no cost sharing for people with Medicare for these COVID-19 monoclonal antibody products:

  • No copayment/coinsurance
  • No deductible

Billing for Administering COVID-19 Monoclonal Antibody Products

Health care providers can bill on a single claim for administering COVID-19 monoclonal antibody products, or submit claims on a roster bill.

  • The EUAs for COVID-19 monoclonal antibody products contain specific requirements for administration that are considerably more complex than for other services that use roster billing. CMS expects health care providers to maintain appropriate medical documentation that supports the medical necessity of the service, including:
    • Documentation that supports that the provider met the terms of the EUAs
    • The name of the provider who ordered or decided to administer the infusion or injection, even in cases where providers use roster billing to submit claims for these services
  • When the government provides COVID-19 monoclonal antibody products for free, providers should only bill for the administration; don’t include the monoclonal antibody product codes on these claims. If you got the product for free, and your systems require a product code to bill for the administration, enter $0.01 for the billed amount.
  • To ensure access during the PHE, Medicare covers and pays for COVID-19 monoclonal antibodies under the COVID-19 vaccine benefit. 
  • If you’re enrolled as a mass immunizer, you may be able to bill Medicare for administering monoclonal antibodies, consistent with the product’s EUA and in accordance with state law and scope of practice. 
  • Mass immunizers may bill using a roster bill or a traditional claim form, such as a CMS-1500 (PDF) or the 837P electronic format. CMS systems will accept roster bills for 1 or more patients that get the same type of shot (or in the case of monoclonal antibodies, same type of infusion or injection) on the same date of service. 
  • For Medicare Advantage Plan patients you treat on or after January 1, 2022 (except for most Medicare Advantage hospice patients), submit claims for administering COVID-19 monoclonal antibody products to the Medicare Advantage Plan. Original Medicare won’t pay these claims beginning in January 2022.

    For most Medicare Advantage hospice patients, submit claims to Original Medicare. If your hospice patient’s Medicare Advantage plan participates in the Hospice Benefit Component of the Value-Based Insurance Design (VBID) Model, submit claims for administering COVID-19 monoclonal antibody products to the Medicare Advantage Plan. Original Medicare won’t pay these claims beginning in January 2022.

  • For Medicare Advantage Plan patients you treated in 2021, submit claims for administering COVID-19 monoclonal antibody products to Original Medicare through your Medicare Administrative Contractor (MAC). Use your patients’ Medicare Beneficiary Identifiers (MBI) 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 use the MAC’s secure portal to look up the MBI for your Medicare patients even if they’re enrolled in a Medicare Advantage Plan.
    • For Part A claims, include Condition Code (CC) 78.
  • Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
    • For Original Medicare patients, Medicare pays RHCs and FQHCs for administering COVID-19 monoclonal antibody products at 100% of reasonable cost through the cost report.
    • For Medicare Advantage patients you treated:
      • On or after January 1, 2022, RHCs and FQHCs should submit claims for administering COVID-19 monoclonal antibody products to the Medicare Advantage Plan. Original Medicare won’t pay these claims beginning in January 2022.
      • In 2021, RHCs and FQHCs should use the cost report to bill for administering COVID-19 monoclonal antibody products.
Page Last Modified:
01/11/2022 04:46 PM