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COVID-19: Tools to Determine if Vaccine Requirements Apply


Thursday, January 27, 2022


Claims, Pricers, & Codes

MLN Matters® Articles





COVID-19: Tools to Determine if Vaccine Requirements Apply

In light of the recent Supreme Court ruling on January 13, 2022, employee vaccination requirements from the Centers for Medicare & Medicaid Services (CMS) now apply to certain Medicare or Medicaid providers and suppliers. Please see below for new and updated tools and resources developed by CMS to help you navigate and determine if these vaccine requirements apply to you. These materials are all available from the CMS Current Emergencies page:


COVID-19 Vaccine Codes: Pfizer Pre-Diluted Vaccine for Patients Ages 12+ & Third Dose for Immunocompromised Patients Ages 5–11

On January 3, the FDA:

  • Authorized an additional pre-diluted formulation (gray cap) for patients 12 years and older
  • Amended the Pfizer-BioNTech COVID-19 vaccine (PDF) emergency use authorization to allow for third pediatric doses (orange cap) for 5–11-year-old solid organ transplant patients or patients with a similar level of immunocompromise

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

More Information:


COVID-19: Vaccine Access in Long-term Care Settings

The federal government is committed to ensuring that residents and staff in long-term care settings, like nursing homes, assisted living, residential care communities, group homes, and senior housing, have access to COVID-19 vaccines to get primary series and booster shots.

We encourage long-term care providers to consider the option that works best for their residents and staff when coordinating access to COVID-19 vaccines, either in the local community or on-site. The CDC has additional details on these options.

As a reminder, through enforcement discretion, CMS will allow Medicare-enrolled immunizers, including but not limited to pharmacies working with the U.S., to bill directly and get direct reimbursement from the Medicare program for vaccinating Medicare skilled nursing facility residents. Find Medicare billing and payment information.


Medicare Diabetes Prevention Program: New for Calendar Year 2022

The calendar year (CY) 2022 Physician Fee Schedule (PFS) final rule and correction notice include information on the Medicare Diabetes Prevention Program (MDPP) expanded model. The MDPP changes that went into effect January 1 include:

  • Shortening the MDPP services period to 1 year for patients who enrolled on or after January 1; the first core session date is the enrollment date
  • Redistributing all ongoing maintenance session payments to the first year with a focus on increasing attendance-based performance payments
  • Removing the ongoing maintenance session payments for patients whose first core session occurs on or after January 1
  • Maintaining the 2021 payment amounts for ongoing maintenance sessions for patients who started MDPP in 2021 or earlier and maintain 5% weight loss and attendance requirements; the first core session date is the enrollment date
  • Waiving the MDPP supplier enrollment fee

Find CY 2022 payment rates.

More Information:


Claims, Pricers, & Codes


Acute Hospital Care at Home: New Occurrence Span Code and Revenue Code

To track inpatient claims submitted for the Acute Hospital Care at Home program, the National Uniform Billing Committee approved the following codes for claims received on or after July 1, 2022:

  • Revenue Code 0161: Hospital at Home, R&B/Hospital at Home
  • Occurrence Span Code 82: Hospital at Home Care Dates

For more information, see the official instruction to your Medicare Administrative Contractor (PDF).


MLN Matters® Articles


April 2022 Update to the Medicare Severity - Diagnosis Related Group (MS-DRG) Grouper and Medicare Code Editor (MCE) Version 39.1 for the International Classification of Diseases, Tenth Revision (ICD-10) Diagnosis Codes for 2019 Novel Coronavirus (COVID-19) Vaccination Status and ICD-10 Procedure Coding System (PCS) Codes for Introduction or Infusion of Therapeutics and Vaccines for COVID-19 Treatment

Learn about new ICD-10 codes for COVID-19 (PDF):

  • Diagnosis codes for reporting vaccination status
  • Procedure codes for introducing or infusing therapeutics, including COVID-19 vaccines
  • MCE edit for unspecified ICD-10-CM diagnosis codes


Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens

Learn about calendar year 2022 travel allowances (PDF):

  • Per mile
  • Flat rate


CY2022 Telehealth Update Medicare Physician Fee Schedule

Learn about telehealth billing changes, including (PDF):

  • 2 new modifiers
  • Telehealth services list update


Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits

Learn about new and discontinued HCPCS codes and those subject to and excluded from CLIA edits. (PDF)


Internet-Only Manual Updates (IOM) for Critical Care, Split/Shared Evaluation and Management Services, Teaching Physicians, & Physician Assistants

CMS revised Medicare manuals (PDF) for:

  • Critical care services
  • Split (or shared) evaluation and management visits
  • Teaching physician services
  • Physician assistant billing and payment


New Waived Tests

Learn about the latest waived tests approved by the FDA under the Clinical Laboratory Improvement Amendments of 1988 (PDF).




Home Infusion Therapy Services Monitoring Report

Read the January 2022 Home Infusion Therapy (HIT) Monitoring Report (PDF) about HIT benefit use from January 1, 2019–March 31, 2021, including:

  • Visits
  • Patients
  • Supplier organizations

More Information:


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