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

CPT Short Descriptor

Labeler Name

Vaccine/Procedure Name

National Payment Allowance Effective for Claims with DOS on or after 03/15/2021 National Payment Allowance Effective for Claims with DOS through 03/14/2021

Effective Dates

91300

SARSCOV2 VAC 30MCG/0.3ML IM

Pfizer

Pfizer-Biontech Covid-19 Vaccine

$0.010[1]

$0.010[1]

12/11/2020 – TBD

0001A

ADM SARSCOV2 30MCG/0.3ML 1ST

Pfizer

Pfizer-Biontech Covid-19 Vaccine Administration – First Dose

$40.000[2]

$16.940[2]

12/11/2020 – TBD

0002A

ADM SARSCOV2 30MCG/0.3ML 2ND

Pfizer

Pfizer-Biontech Covid-19 Vaccine Administration – Second Dose

$40.000[2]

$28.390[2]

12/11/2020 – TBD

91301

SARSCOV2 VAC 100MCG/0.5ML IM

Moderna

Moderna Covid-19 Vaccine

$0.010[1]

$0.010[1]

12/18/2020 – TBD

0011A

ADM SARSCOV2 100MCG/0.5ML1ST

Moderna

Moderna Covid-19 Vaccine Administration – First Dose

$40.000[2]

$16.940[2]

12/18/2020 – TBD

0012A

ADM SARSCOV2 100MCG/0.5ML2ND

Moderna

Moderna Covid-19 Vaccine Administration – Second Dose

$40.000[2]

 $28.390[2]

12/18/2020 – TBD

91302

SARSCOV2 VAC 5X10^10VP/.5MLIM

AstraZeneca

AstraZeneca Covid-19 Vaccine

$0.010[1]

Code not active during this time

xx/xx/xxxx – TBD

0021A

ADM SARSCOV2 5X10^10VP/.5ML 1

AstraZeneca

AstraZeneca Covid-19 Vaccine Administration – First Dose

$40.000[2]

Code not active during this time

xx/xx/xxxx – TBD

0022A

ADM SARSCOV2 5X10^10VP/.5ML 2

AstraZeneca

AstraZeneca Covid-19 Vaccine Administration – Second Dose

$40.000[2]

Code not active during this time

xx/xx/xxxx – TBD

91303 SARSCOV2 VAC AD26 .5ML IM Janssen Janssen Covid-19 Vaccine[3]*** $0.010[1] $0.010[1] 02/27/2021 – TBD
0031A ADM SARSCOV2 VAC AD26 .5ML Janssen Janssen Covid-19 Vaccine Administration[3]*** $40.000[2] $28.390[2] 02/27/2021 – TBD

91304

SARSCOV2 VAC 5MCG/0.5ML IM

Novavax

Novavax Covid-19 Vaccine

$0.010[1]

Code not active during this time

xx/xx/xxxx – TBD

0041A

ADM SARSCOV2 5MCG/0.5ML 1ST

Novavax

Novavax Covid-19 Vaccine Administration – First Dose

$40.000[2]

Code not active during this time

xx/xx/xxxx – TBD

0042A

ADM SARSCOV2 5MCG/0.5ML 2ND

Novavax

Novavax Covid-19 Vaccine Administration – Second Dose

$40.000[2]

Code not active during this time

xx/xx/xxxx – TBD

[1] Since we anticipate that providers, initially, will not incur a cost for the product, CMS will update the payment allowance at a later date.  Providers should not bill for the product if they received it for free.

[2] These rates will also be geographically adjusted for many providers. For providers and suppliers with payments that are geographically adjusted by the methodology used by the Medicare Physician Fee Schedule (MPFS), files with the geographically adjusted payment rates for COVID-19 vaccine administration are included in the “Additional Resources” section below. Certain settings utilize other payment methodologies, such as payment based on reasonable costs.

[3] Johnson & Johnson COVID-19 Vaccine

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

HCPCS Code

CPT Short Descriptor

Labeler Name

Vaccine/Procedure Name

National Payment Allowance Effective for Claims with DOS on or after 05/6/2021

National Payment Allowance Effective for Claims with DOS through 05/5/2021

Effective Dates

Q0239

Bamlanivimab-xxxx

Eli Lilly

Injection, bamlanivimab, 700 mg

Code not active during this time period

 $0.010[1]

11/10/2020 – 04/16/2021[4]

M0239

 

Bamlanivimab-xxxx infusion

Eli Lilly

Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring

Code not active during this time period

$309.600[3]

11/10/2020 – 04/16/2021[4]

Q0243

Casirivimab and imdevimab

Regeneron

Injection, casirivimab and imdevimab, 2400 mg

$0.010[1]

$0.010[1]

11/21/2020 – TBD

M0243

Casirivi and imdevi infusion

Regeneron

Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring

$450.00[3]

$309.600[3]

11/21/2020 – TBD

M0244

Casirivi and imdevi infus hm

Regeneron

Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency.

$750.00[3]

Code not active during this time period

05/06/2021 – TBD

Q0245 Bamlanivimab and etesevima Eli Lilly Injection, bamlanivimab and etesevimab, 2100 mg $0.010[1] $0.010[1] 02/09/2021 – TBD
M0245 Bamlan and etesev infusion Eli Lilly intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring $450.00[3] $309.600[3] 02/09/2021 – TBD

M0246

Bamlan and etesev infus home

Eli Lilly

Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency.

$750.00[3]

Code not active during this time period

05/06/2021 – TBD

[1] Since we anticipate that providers, initially, will not incur a cost for the product, CMS will update the payment allowance at a later date.  Providers should not bill for the product if they received it for free.

[3] These rates will be geographically adjusted for many providers.  For providers and suppliers with payments that are geographically adjusted by the methodology used by the Medicare Physician Fee Schedule (MPFS), files with the geographically adjusted payment rates for monoclonal antibody administration are included in the “Additional Resources” section below. Certain settings utilize other payment methodologies, such as payment based on reasonable costs.

[4]On April 16, 2021, the FDA revoked the EUA that allowed for the investigational monoclonal antibody therapy bamlanivimab, when administered alone, to be used for the treatment of mild-to-moderate COVID-19 in adults and certain pediatric patients. Due to this revocation, Medicare will not pay for claims with HCPCS codes M0239 or Q0239 with dates of service after 4/16/2021.

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.

Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction

Covid-19 NDC-HCPCS crosswalk

COVID-19 Vaccination Resources at CDC

COVID-19 CPT vaccine and immunization codes - AMA

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

Bamlanivimab Emergency Use Authorization

Casirivimab and imdevimab Emergency Use Authorization (ZIP)

Bamlanivimab and etesevimab Emergency Use Authorization

Pfizer-BioNTech COVID-19 Vaccine Emergency Use Authorization

Moderna COVID-19 Vaccine Emergency Use Authorization (PDF)

Janssen COVID-19 Vaccine Emergency Use Authorization

Fact Sheet for Healthcare Providers - Emergency Use Authorization of bamlanivimab

Fact Sheet for Healthcare Providers - Emergency Use Authorization of casirivimab and imdevimab

Fact Sheet for Healthcare Providers - Emergency Use Authorization of bamlanivimab and etesevimab

Fact Sheet for Healthcare Providers - Emergency Use Authorization of Pfizer-BioNTech COVID-19 Vaccine

Fact Sheet for Healthcare Providers - Emergency Use Authorization of Moderna COVID-19 Vaccine

Fact Sheet for Healthcare Providers - Emergency Use Authorization of Janssen COVID-19 Vaccine

Information about Public Health Emergency

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

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

2021 Geographically-adjusted Payment Rates for Monoclonal Antibody Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated February 16, 2021 for addition of bamlanivimab and etesevimab*

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

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 5/6/2021 to account for change in payment rate and addition of new codes for home administration* [For claims with dates of service 5/6/2021 through 12/31/2021]

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 3/15/2021 to account for change in payment rate* [For claims with dates of service 3/15/2021 – 12/31/2021]

 

Page Last Modified:
05/06/2021 04:51 PM