COVID-19 Vaccines and Monoclonal Antibodies

Medicare Part B Payment for COVID-19 Vaccines and Certain Monoclonal Antibodies during the Public Health Emergency

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.  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.  For more information, review the COVID-19 provider toolkit.

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 or HCPCS Code

CPT or HCPCS 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  (Aged 12 years and older) (Purple Cap)

$0.010[1]

$0.010[1]

12/11/2020 – TBD

0001A

ADM SARSCOV2 30MCG/0.3ML 1ST

Pfizer

Pfizer-BioNTech Covid-19 Vaccine (Purple Cap) 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 (Purple Cap) Administration – Second Dose

$40.000[2]

$28.390[2]

12/11/2020 – TBD

0003A

ADM SARSCOV2 30MCG/0.3ML 3RD

Pfizer

Pfizer-BioNTech Covid-19 Vaccine (Purple Cap) Administration – Third Dose

$40.000[2]

Code not active during this time

08/12/2021 – TBD

0004A[4]

ADM SARSCOV2 30MCG/0.3ML BST

Pfizer

Pfizer-BioNTech Covid-19 Vaccine (Purple Cap) Administration – Booster

$40.000[2]

Code not active during this time

09/22/2021 – TBD

91301

SARSCOV2 VAC 100MCG/0.5ML IM

Moderna

Moderna Covid-19 Vaccine (Aged 12 years and older) (Red Cap)

$0.010[1]

$0.010[1]

12/18/2020 – TBD

0011A

ADM SARSCOV2 100MCG/0.5ML1ST

Moderna

Moderna Covid-19 Vaccine (Red Cap) Administration – First Dose

$40.000[2]

$16.940[2]

12/18/2020 – TBD

0012A

ADM SARSCOV2 100MCG/0.5ML2ND

Moderna

Moderna Covid-19 Vaccine (Red Cap) Administration – Second Dose

$40.000[2]

$28.390[2]

12/18/2020 – TBD

0013A

ADM SARSCOV2 100MCG/0.5ML3RD

Moderna

Moderna Covid-19 Vaccine (Red Cap) Administration – Third Dose

$40.000[2]

Code not active during this time

08/12/2021 – 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 (Aged 18 years and older)[3]

$0.010[1]

$0.010[1]

02/27/2021 – TBD

0031A

ADM SARSCOV2 VAC AD26 .5ML

Janssen

Janssen Covid-19 Vaccine Administration - First Dose[3]

$40.000[2]

$28.390[2]

02/27/2021 – TBD

0034A

ADM SARSCOV2 VAC AD26 .5ML B

Janssen

Janssen Covid-19 Vaccine Administration -  Booster[3]

$40.000[2]

 Code not active during this time

10/20/2021 – TBD

91304

SARSCOV2 VAC 5MCG/0.5ML IM

Novavax

Novavax Covid-19 Vaccine, Adjuvanted (Aged 12 years and older)

$0.010[1]

Code not active during this time

07/13/2022 – TBD

0041A

ADM SARSCOV2 5MCG/0.5ML 1ST

Novavax

Novavax Covid-19 Vaccine, Adjuvanted  Administration – First Dose

$40.000[2]

Code not active during this time

07/13/2022 – TBD

0042A

ADM SARSCOV2 5MCG/0.5ML 2ND

Novavax

Novavax Covid-19 Vaccine, Adjuvanted  Administration – Second Dose

$40.000[2]

Code not active during this time

07/13/2022 – TBD

0044A

ADM SARSCOV2 5MCG/0.5ML BST

Novavax

Novavax Covid-19 Vaccine, Adjuvanted Administration - Booster

$40.000[2]

Code not active during this time

10/19/2022 – TBD

91305

SARSCOV2 VAC 30 MCG TRS-SUCR

Pfizer

Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Aged 12 years and older) (Gray Cap)

$0.010[1]

Code not active during this time

01/03/2022 – TBD

0051A

ADM SARSCV2 30MCG TRS-SUCR 1

Pfizer

Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - First dose

$40.000[2]

Code not active during this time

01/03/2022 – TBD

0052A

ADM SARSCV2 30MCG TRS-SUCR 2

Pfizer

Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - Second dose

$40.000[2]

Code not active during this time

01/03/2022 – TBD

0053A

ADM SARSCV2 30MCG TRS-SUCR 3

Pfizer

Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - Third dose

$40.000[2]

Code not active during this time

01/03/2022 – TBD

0054A[4]

ADM SARSCV2 30MCG TRS-SUCR B

Pfizer

Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - Booster

$40.000[2]

Code not active during this time

01/03/2022 – TBD

91306

SARSCOV2 VAC 50MCG/0.25ML IM

Moderna

Moderna Covid-19 Vaccine (Aged 18 years and older) (Red Cap) (Low Dose)

$0.010[1]

Code not active during this time

10/20/2021 – TBD

0064A[4]

ADM SARSCOV2 50MCG/0.25MLBST

Moderna

Moderna Covid-19 Vaccine (Red Cap) (Low Dose) Administration - Booster

$40.000[2]

Code not active during this time

10/20/2021 – TBD

91307

SARSCOV2 VAC 10 MCG TRS-SUCR

Pfizer

Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 5 years through  11 years) (Orange Cap)

$0.010[1]

Code not active during this time

10/29/2021 - TBD

0071A

ADM SARSCV2 10MCG TRS-SUCR 1

Pfizer

Pfizer-BioNTech Covid-19 Pediatric Vaccine (Orange Cap) Administration - First dose

$40.000[2]

Code not active during this time

10/29/2021 - TBD

0072A

ADM SARSCV2 10MCG TRS-SUCR 2

Pfizer

Pfizer-BioNTech Covid-19 Pediatric Vaccine (Orange Cap) Administration - Second dose

$40.000[2]

Code not active during this time

10/29/2021 - TBD

0073A

ADM SARSCV2 10MCG TRS-SUCR 3

Pfizer

Pfizer-BioNTech Covid-19 Pediatric Vaccine (Orange Cap) Administration - Third dose

$40.000[2]

Code not active during this time

01/03/2022 - TBD

0074A[4]

ADM SARSCV2 10MCG TRS-SUCR B

Pfizer

Pfizer-BioNTech Covid-19 Pediatric Vaccine (Orange Cap) Administration - Booster

$40.000[2]

Code not active during this time

05/17/2022 - TBD

91308

SARSCOV2 VAC 3MCG TRS-SUCR

Pfizer

Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap)

$0.010[1]

Code not active during this time

06/17/2022 - TBD

0081A

ADM SARSCOV2 3MCG TRS-SUCR 1

Pfizer

Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - First dose

$40.000[2]

Code not active during this time

06/17/2022 - TBD

0082A

ADM SARSCOV2 3MCG TRS-SUCR 2

Pfizer

Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - Second dose

$40.000[2]

Code not active during this time

06/17/2022 - TBD

0083A

ADM SARSCOV2 3MCG TRS-SUCR 3

Pfizer

Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - Third dose

$40.000[2]

Code not active during this time

06/17/2022 - TBD

91309

SARSCOV2 VAC 50MCG/0.5ML IM

Moderna

Moderna Covid-19 Vaccine (Aged 6 years through 11 years or aged 18 years and older) (Blue Cap with purple border) 50MCG/0.5ML[5]

$0.010[1]

Code not active during this time

03/29/2022 - TBD

0091A

ADM SARSCOV2 50 MCG/.5 ML1ST

Moderna

Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - First dose

$40.000[2]

Code not active during this time

06/17/2022 - TBD

0092A

ADM SARSCOV2 50 MCG/.5 ML2ND

Moderna

Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - Second dose

$40.000[2]

Code not active during this time

06/17/2022 - TBD

0093A

ADM SARSCOV2 50 MCG/.5 ML3RD

Moderna

Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - Third dose

$40.000[2]

Code not active during this time

06/17/2022 - TBD

0094A[4]

ADM SARSCOV2 50MCG/0.5 MLBST

Moderna

Moderna Covid-19 Vaccine (Aged 18 years and older) (Blue Cap with purple border) 50MCG/0.5ML Administration - Booster

$40.000[2]

Code not active during this time

03/29/2022 - TBD

91311

SARSCOV2 VAC 25MCG/0.25ML IM

Moderna

Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) 250MCG/0.25ML

$0.010[1]

Code not active during this time

06/17/2022 - TBD

0111A

ADM SARSCOV2 25MCG/0.25ML1ST

Moderna

Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - First dose

$40.000[2]

Code not active during this time

06/17/2022 - TBD

0112A

ADM SARSCOV2 25MCG/0.25ML2ND

Moderna

Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - Second dose

$40.000[2]

Code not active during this time

06/17/2022 - TBD

0113A

ADM SARSCOV2 25MCG/0.25ML3RD

Moderna

Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - Third dose

$40.000[2]

Code not active during this time

06/17/2022 - TBD
91312 SARSCOV2 VAC BVL 30MCG/0.3M Pfizer Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product (Aged 12 years and older) (Gray Cap) $0.010[1] Code not active during this time 08/31/2022 – TBD
0124A ADM SARSCV2 BVL 30MCG/.3ML B Pfizer Pfizer-BioNTech COVID-19 Vaccine, Bivalent (Gray Cap) Administration – Booster Dose $40.000[2] Code not active during this time 08/31/2022 – TBD
91313 SARSCOV2 VAC BVL 50MCG/0.5ML Moderna Moderna COVID-19 Vaccine, Bivalent Product (Aged 12 years and older) (Dark Blue Cap with gray border)[6] $0.010[1] Code not active during this time 08/31/2022 – TBD[6]
0134A ADM SARSCV2 BVL 50MCG/.5ML B Moderna Moderna COVID-19 Vaccine, Bivalent (Aged 12 years and older) (Dark Blue Cap with gray border) Administration – Booster Dose[6] $40.000[2] Code not active during this time 08/31/2022 – TBD[6]

91314

SARSCOV2 VAC BVL 25MCG/0.25ML

Moderna

Moderna COVID-19 Vaccine, Bivalent Product (Aged 6 years through 11 years) (Dark Blue Cap with gray border)

$0.010[1]

Code not active during this time

10/12/2022 – TBD

0144A

ADM SARSCV2 BVL 25MCG/.25ML B

Moderna

Moderna COVID-19 Vaccine, Bivalent (Aged 6 years through 11 years) (Dark Blue Cap with gray border) Administration – Booster Dose

$40.000[2]

Code not active during this time

10/12/2022 – TBD

91315

SARSCOV2 VAC BVL 10MCG/0.2ML

Pfizer

Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product (Aged 5 years through 11 years) (Orange Cap)

$0.010[1]

Code not active during this time

10/12/2022 – TBD

0154A

ADM SARSCV2 BVL 10MCG/.2ML B

Pfizer

Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product (Aged 5 years through 11 years) (Orange Cap) Administration – Booster Dose

$40.000[2]

Code not active during this time

10/12/2022 – TBD

91316

SARSCOV2 VAC BVL 10MCG/0.2ML

Moderna

Moderna COVID-19 Vaccine, Bivalent Product (Aged 6 months through 5 years) (Dark Pink Cap and a label with a yellow box)

$0.010[1]

Code not active during this time

12/08/2022 – TBD

0164A

ADM SRSCV2 BVL 10MCG/0.2ML B

Moderna

Moderna COVID-19 Vaccine, Bivalent (Aged 6 months through 5 years) (Dark Pink Cap and label with a yellow box) Administration – Booster Dose

$40.000[2]

Code not active during this time

12/08/2022 – TBD

91317

SARSCOV2 VAC BVL 3MCG/0.2ML

Pfizer

Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product (Aged 6 months through 4 years) (Maroon Cap)

$0.010[1]

Code not active during this time

12/08/2022 – TBD

0173A

ADM SARSCV2 BVL 3MCG/0.2ML 3

Pfizer

Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - Third dose

$40.000[2]

Code not active during this time

12/08/2022 – TBD

M0201

Covid-19 vaccine home admin

Home vaccine admin

Covid-19 vaccine administration inside a patient's home; reported only once per individual home per date of service when only covid-19 vaccine administration is performed at the patient's home

$35.50[2]

Code not active during this time

 06/08/2021 - 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.

[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. Starting January 1, 2023, we’ll also annually update the COVID-19 vaccine payment rates to reflect changes in costs related to administering preventive vaccines.

[3] Johnson & Johnson COVID-19 vaccine. On May 5, 2022, the FDA limited the authorized use of the Janssen COVID-19 vaccine.

[4] Administration booster codes should be billed for all applicable booster doses as approved and/or authorized by the FDA.

[5] On June 17, 2022, FDA authorized the 50MCG/0.5ML presentation of the Moderna COVID-19 Vaccine to provide primary series doses in individuals 6 years through 11 years of age in addition to the 3/29/2022 FDA authorization to provide booster vaccination doses in individuals 18 years and older.

[6] On October 12, 2022, the FDA authorized the Moderna bivalent product (dark blue cap with gray border) and its administration for use as a single booster dose in individuals 12 years through 17 years of age in addition to the 8/31/2022 FDA authorization as a single booster dose in individuals 18 years and older.

Payment Allowances and Effective Dates for COVID-19 Monoclonal Antibodies and their Administration During the Public Health Emergency:

HCPCS Code

 HCPCS 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

Q0220

Tixagev and cilgav, 300mg

AstraZeneca

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

$0.010[1]

Code not active during this time period

12/08/2021 - TBD

Q0221

Tixagev and cilgav, 600mg

AstraZeneca

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), 600 mg

$0.010[1]

Code not active during this time period

02/24/2022 - TBD

M0220

Tixagev and cilgav inj

AstraZeneca

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

$150.50[3]

Code not active during this time period

12/08/2021 - TBD

M0221

Tixagev and cilgav inj hm

AstraZeneca

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

 

$250.50[3]

Code not active during this time period

12/08/2021 - TBD

Q0222

Note: This product isn’t currently authorized[11]

Bebtelovimab 175 mg

Eli Lilly

Injection, bebtelovimab, 175 mg

$2394.00[1] [1a]

Code not active during this time period

02/11/2022 - TBD

M0222

Note: This product isn’t currently authorized[11]

Bebtelovimab injection

Eli Lilly

Intravenous injection, bebtelovimab, includes injection and post administration monitoring

$350.50[3]

Code not active during this time period

02/11/2022 - TBD

M0223

Note: This product isn’t currently authorized[11]

Bebtelovimab injection home

Eli Lilly

Intravenous injection, bebtelovimab, 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

$550.50[3]

Code not active during this time period

02/11/2022 - TBD

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]

Q0240[6]
Note: This product isn’t currently authorized[9]

Casirivi and imdevi 600mg

Regeneron

Injection, casirivimab and imdevimab, 600 mg

 $0.010[1]

Code not active during this time period

07/30/2021 – TBD

M0240[6]
Note: This product isn’t currently authorized[9]

Casiri and imdev repeat

Regeneron

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

 $450.00[3]

Code not active during this time period

07/30/2021 – TBD

M0241[6]
Note: This product isn’t currently authorized[9]

Casiri and imdev repeat hm

Regeneron

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

 $750.00[3]

Code not active during this time period

07/30/2021 – TBD

Q0243
Note: This product isn’t currently authorized[9]

Casirivimab and imdevimab

Regeneron

Injection, casirivimab and imdevimab, 2400 mg

 $0.010[1]

$0.010[1]

11/21/2020 – TBD

M0243
Note: This product isn’t currently authorized[9]

Casirivi and imdevi inj

Regeneron

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

$450.00[3]

$309.600[3]

11/21/2020 – TBD

Q0244[5]
Note: This product isn’t currently authorized[9]

Casirivi and imdevi 1200 mg

Regeneron

Injection, casirivimab and imdevimab, 1200 mg

 $0.010[1]

$0.010[1]

06/03/2021 – TBD

M0244
Note: This product isn’t currently authorized[9]

Casirivi and imdevi inj hm

Regeneron

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

$750.00[3]

Code not active during this time period

05/06/2021 – TBD

Q0245[8]
Note: This product isn’t currently authorized[9]

Bamlanivimab and etesevima

Eli Lilly

Injection, bamlanivimab and etesevimab, 2100 mg

$0.010[1]

$0.010[1]

02/09/2021 – TBD

M0245[8]
Note: This product isn’t currently authorized[9]

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[8]
Note: This product isn’t currently authorized[9]

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

Q0247[7]

Note: This product isn’t currently authorized[10]

Sotrovimab

GSK

Injection, sotrovimab, 500 mg

$2394.00

Code not active during this time period

05/26/2021 – TBD

M0247

Note: This product isn’t currently authorized[10]

Sotrovimab infusion

GSK

Intravenous infusion, sotrovimab, includes infusion and post administration monitoring

$450.00[3]

Code not active during this time period

05/26/2021 – TBD

M0248

Note: This product isn’t currently authorized[10]

Sotrovimab inf, home admin

GSK

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 emergency

$750.00[3]

Code not active during this time period

05/26/2021 – TBD

Q0249[2]

Tocilizumab for COVID-19

Genentech

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

$6.572

Code not active during this time period

06/24/2021 - TBA

M0249

Adm Tocilizu COVID-19 1st

Genentech

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

$450.00[3]

Code not active during this time period

06/24/2021 - TBA

M0250

Adm Tocilizu COVID-19 2nd

Genentech

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

$450.00[3]

Code not active during this time period

06/24/2021 - TBA

[1] Providers shouldn't bill for the product if they received it for free through the USG-purchased inventory.

[1a] Payment rate effective for dates of service on or after August 15, 2022. Providers should only bill Medicare for commercially-purchased products.

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

[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. As a result, Medicare won't pay for claims with HCPCS codes M0239 or Q0239 with dates of service after April 16, 2021.

[5] On June 3, 2021, the FDA revised the EUA for casirivimab and imdevimab to change the allowed dosing regimen from 2400 mg to 1200 mg, and allow providers to administer the combination product by subcutaneous injection in limited circumstances. As a result, CMS issued a new product code for casirivimab and imdevimab (Q0244) and updated the descriptors for the existing administration codes (M0243/M0244). 

[6] On July 30, 2021, the FDA revised the EUA for casirivimab and imdevimab to allow its use for post-exposure prophylaxis (PEP) in certain adult and pediatric patients. For patients who meet the criteria for repeat dosing, the authorized dosage is an initial dose of 1200 mg, followed by subsequent repeat dosing of 600 mg once every 4 weeks for the duration of ongoing exposure. As a result, CMS issued a new product code for casirivimab and imdevimab of 600 mg (Q0240), and 2 new codes for the administration of repeat doses of casirivimab and imdevimab (M0240/M0241). Providers and suppliers who administer casirivimab and imdevimab for PEP should use M0243 or M0244 for administering the first dose and M0240 or M0241 for administering subsequent repeat doses.

[7] When the government provides monoclonal antibody products to treat COVID-19 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.

[8] On September 16, 2021, the FDA revised the EUA for bamlanivimab and etesevimab, administered together, to allow its use for post-exposure prophylaxis (PEP) in certain adult and pediatric patients. Providers and suppliers should use Q0245 and M0245 or M0246 to bill for administering bamlanivimab and etesevimab for PEP.

[9] On January 24, 2022, the FDA announced that, due to the high frequency of the Omicron variant, REGEN-COV (casirivimab and imdevimab, administered together) isn’t currently authorized in any U.S region. Therefore, you may not administer REGEN-COV for treatment or post-exposure prevention of COVID-19 under the EUA until further notice.

[10] On April 5, 2022, the FDA announced that, due to the high frequency of the Omicron BA.2 sub-variant, sotrovimab isn’t currently authorized in any U.S. region. Therefore, you may not administer sotrovimab to treat COVID-19 under the EUA until further notice.

[11] On November 30, 2022, the FDA announced that bebtelovimab isn’t currently authorized in any U.S. region because it isn’t expected to neutralize Omicron sub-variants BQ.1 and BQ.1.1. Therefore, you may not administer bebtelovimab to treat COVID-19 under the EUA until further notice.

Additional Resources:

Following links contain helpful information for providers. Product NDCs can be found in the EUA Fact Sheet for Healthcare Providers and can be used to identify the appropriate HCPCS codes for each product and its administration. NDC - HCPCS crosswalk is available in CMS ASP crosswalk zip folder. Long, medium, and short descriptors of COVID-19 CPT codes are available from AMA website.

COVID-19 CPT vaccine and immunization codes - AMA

COVID-19 NDC-HCPCS crosswalk

COVID-19 Vaccination Resources at CDC

COVID-19 Vaccination Training Programs and Reference Materials for Healthcare Professionals

Information about Public Health Emergency

Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction

Quick reference guide to the coding structure for COVID-19 vaccine CPT reporting

Geographically-adjusted Payment Rates

2023

Jan - Dec 2023 Geographically-adjusted Payment Rates for COVID-19 Vaccine Administration [For claims with dates of service 01/01/2023 through 12/31/2023]

Jan - Dec 2023 Geographically-adjusted Payment Rates for Monoclonal Antibody Administration [For claims with dates of service 01/01/2023 through 12/31/2023]

2022

Jan - Dec 2022 Geographically-adjusted Payment Rates for Monoclonal Antibody Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated 02/17/2022 to reflect the new codes for bebtelovimab [For claims with dates of service 02/11/2022 through 12/31/2022]

Jan - Dec 2022 Geographically-adjusted Payment Rates for COVID-19 Vaccine Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated 10/25/2022 to reflect the new code for Novavax COVID-19 vaccine, Adjuvanted booster dose [For claims with dates of service 10/19/2022 through 12/31/2022]

Jan - Dec 2022 Geographically-adjusted Payment Rates for COVID-19 Vaccine Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated 12/20/2022 to reflect the new codes for Moderna and Pfizer-BioNTech pediatric bivalent (updated COVID-19 vaccines) booster dose/ third dose [For claims with dates of service 12/08/2022 through 12/31/2022]

2021

Jan - March 2021 Geographically-adjusted Payment Rates for COVID-19 Vaccine Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated February 16, 2021 for addition of the COVID-19 Janssen vaccine* [For claims with dates of service of 1/1/2021 through 3/14/2021]

March - Dec 2021 Geographically-adjusted Payment Rates for COVID-19 Vaccine Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated 11/02/2021 to account for effective dates for Pfizer-BioNTech COVID-19 Pediatric Vaccine [For claims with dates of service 3/15/2021 through 12/31/2021]

Jan-May 2021 Geographically-adjusted Payment Rates for Monoclonal Antibody Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) [For claims with dates of service of 1/1/2021 through 5/5/2021]

May-Dec 2021 Geographically-adjusted Payment Rates for Monoclonal Antibody Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated 12/23/2021 to account for new codes for tixagevimab co-packaged with cilgavimab* [For claims with dates of service 5/6/2021 through 12/31/2021]

2020

2020 Geographically-adjusted Payment Rates for Monoclonal Antibody Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) 

2020 Geographically-adjusted Payment Rates for COVID-19 Vaccine Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP)

Monoclonal Antibody Emergency Use Authorizations (EUAs) & Fact Sheets

Vaccine Authorization Letters & Fact Sheets

 

 

Page Last Modified:
01/25/2023 02:46 PM
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