Basic Requirements to Bill Medicare
As a provider you must fulfill the following requirements to bill COVID-19 vaccine shots administration to Medicare:
- You must be a Medicare-enrolled provider to bill Medicare for administering COVID-19 vaccines to Medicare patients. CMS has provided detailed information for healthcare providers on enrolling 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).
- If you administer additional vaccine doses on or after August 12, 2021, to immunocompromised Medicare patients, consistent with the FDA’s updated emergency use authorizations (EUAs), acknowledge and document (e.g., in the medical record) your patient’s self-reported qualifying conditions for the additional dose and bill the appropriate billing code for administering an additional dose. 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. You will find detailed information on Medicare Part B payment for COVID-19 vaccines and certain monoclonal antibodies during the public health emergency, here.
- If you administer pediatric doses on or after October 29, 2021, for patients 5-11 years old, consistent with the FDA’s updated EUA, bill the appropriate billing code for administering the pediatric dose.
- If you administer booster doses, bill the appropriate billing code for administering all booster doses consistent with the FDA’s updated EUAs.
- If you administer second Pfizer BioNTech or Moderna booster doses on or after March 29, 2022, use the Pfizer BioNTech and Moderna codes for booster doses.
- When the government provides COVID-19 vaccines at no cost, and only bills 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.
Billing Patients without Medicare Coverage
You might be submitting claims in scenarios like:
- They only have Medicare Part A but not Part B coverage (or supplemental coverage for Part B services, like vaccine administration)
- Their health insurance doesn’t include the COVID-19 vaccine administration fees as a covered benefit (like Medicare Part A only)
- Their health insurance covers the COVID-19 vaccine administration but with cost-sharing
Patients without health insurance can also get the COVID-19 vaccine and administration at no cost. If you vaccinate these patients, you were able to request payment for administering the vaccine through the HRSA COVID-19 Uninsured Program. On April 5, 2022, at 11:59 pm ET, the HRSA COVID-19 Uninsured Program stopped accepting vaccination claims due to insufficient funds.
If you submitted a claim before the deadline, the claim will be paid subject to eligibility and availability of funds. Providers may use the 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.
Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. For provider education, we share the latest billing guidelines and proposed/final acts that directly affect insurance reimbursements for any medical practice.
Our expert team is well versed and updated with billing and coding guidelines which ensure quick and accurate insurance reimbursements.
To know more about how we can assist you in receiving accurate insurance reimbursement for COVID-19 vaccine shot administration, contact us at info@medicalbillersandcoders.com/ 888-357-3226
