As the end of the pandemic is in sight (hopefully), with emergency use authorization of a COVID-19 vaccine, it’s the right time for healthcare organizations to strategize COVID-19 vaccine billing. Recently AMA added CPT code for Janssen’s COVID-19 vaccine. Janssen’s COVID-19 vaccine is the fourth vaccine candidate to get its own CPT code from AMA, following the candidates from Pfizer, Moderna and AstraZeneca.
These unique CPT codes are created to clinically distinguish each vaccine and immunization administration for better tracking, reporting and analysis that supports data-driven planning and allocation. Note that providers cannot bill payers for vaccine doses which they received for free. They have to submit claims for the administration of these vaccines.
Earlier, CMS has stated that it will provide Medicare reimbursement for COVID-19 vaccines and their administration as long as the vaccines are authorized for emergency use or approved by the FDA. For broad coverage of the vaccine, CMS will reimburse providers under Medicare Part B, rather than Part D. Medicare plans to pay providers 95 percent of the average wholesale price of the vaccine as it does with the influenzas and pneumococcal vaccines covered under Part B. However, providers cannot bill Medicare for vaccines they receive for free from the government, CMS states.
For the administration of the vaccines, the payment allowances are currently $16.94 for the first dose of a vaccine and $28.39 for the second dose. CMS notes that these rates will also be geographically adjusted in 2021. Vaccines that require a single dose will be reimbursed at a rate of $28.39. Additionally, if providers administer the vaccine during a ‘significant, separately identifiable evaluation and management (E/M) service, such as an office visit,’ they can document the work and report an E/M code in addition to vaccine and administration codes, the American Academy of Family Physicians advises.
Medicaid will also reimburse providers for COVID-19 vaccines and shot administration, and the programs must compensate Medicaid providers for an administration fee or office visits, even if the vaccine is free to patients, according to an interim final rule effective during the public health emergency. Medicaid reimbursement rates will vary by state and type of arrangement, for example, fee-for-service or managed care. Reimbursement rates will also vary among private payers. But federal regulations also require the payers to cover COVID-19 vaccines and administration even if they are provided through an out-of-network provider.
Finally, for uninsured patients, providers can seek reimbursement for the vaccine and administration through the Provider Relief Fund, which is covering COVID-19 care for the uninsured. They will generally be reimbursed at Medicare rates, subject to available funding, according to the Provider Relief Fund website.
To bill Medicare for COVID-19 vaccine shot administration, providers can either submit a single claim or via roster billing for multiple patients, CMS says. Providers must administer shots to at least five patients on the same date of service to submit claims via rostering billing, unless the institution is an inpatient hospital, the agency adds. Providers need to be enrolled in Medicare to bill the public payer for COVID-19 vaccine administration. Although, providers participating in a Medicare Advantage plan should submit claims to traditional Medicare for all patients enrolled in the plan in 2021, CMS states.
For providers seeking reimbursement for uninsured patients, they can request claims reimbursement electronically via the COVID-19 Uninsured Program Portal. The Portal will only accept claims submitted using an 837 EDI transaction set. Billing processes for state Medicaid programs and private payers will vary. Providers should communicate with a plan’s designated point-of-contact for details on how to submit claims for the COVID-19 vaccine and administration.
The Administration is providing support to health care providers fighting the COVID-19 pandemic through the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program. This program provides reimbursements on a rolling basis directly to eligible providers for claims that are attributed to the testing, treatment, and vaccine administration for COVID-19 for uninsured individuals. The program is being administered by UnitedHealth Group through a contract with the U.S. Department of Health and Human Services' Health Resources and Services Administration (HRSA).
For claims for COVID-19 Testing and Testing-Related Items and Services, a patient is considered uninsured if the patient does not have coverage through an individual, or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program at the time the services were rendered.
For claims for treatment for positive cases of COVID-19, a patient is considered uninsured if the patient did not have any health care coverage at the time the services were rendered. For claims for vaccine administration, this means that the patient did not have any health care coverage at the time the service was rendered.
Health care entities who have conducted COVID-19 testing of uninsured individuals, provided treatment to uninsured individuals with a COVID-19 primary diagnosis, or administered a licensed or authorized COVID-19 vaccine to uninsured individuals on or after February 4, 2020, can request claims reimbursement through the program electronically and will be reimbursed generally at Medicare rates.
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