NAHRI Professional Advocacy Committee guidance on vaccine administration

Wednesday, March 31, 2021

by Committee Representatives Zarina Khabibulina, MD, CCS, CCM, CDIP; William L. Malm, RN, ND, CMAS, CRCR; John D. Settlemyer, MBA, MHA, CPC; Denise Williams, COC, CHRI

Some providers appear to be struggling with “how” and “whether or not” to bill for COVID-19 vaccine administrations. On March 15, 2021, CMS increased the per-injection reimbursement to $40. CMS has recognized that there is added cost to the administering provider because of the increased resources involved in mass immunizations required to control a pandemic. Providers should be filing claims to all payers as appropriate. There is no patient responsibility for the vaccine, which is free, or for the administration of the vaccine. 

The CMS Benefit Policy Manual describes the coverage for vaccines and the administration services as “Vaccinations or inoculations are excluded as immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition.”

So, how has COVID-19 impacted this coverage under Medicare? The COVID-19 vaccine falls under CMS’ benefit category for vaccines as it is directly related to direct exposure to a disease or condition. The National Uniform Billing Committee designated revenue code 0771 for vaccine administration services. 

Similar to the HCPCS Level II codes that have been long established for the administration of hepatitis B and influenza vaccines, CMS created specific codes to describe the COVID-19 vaccine and administration. These codes are product specific and can be found on the CMS COVID-19 Vaccines and Monoclonal Antibodies website.

Additional information is located at CMS’ Medicare Billing for COVID-19 Vaccine Shot Administration  and COVID-19 Vaccines and Monoclonal Antibodies websites.

One significant difference in billing for the COVID-19 vaccine is that at the time of this writing, there is no cost to the provider for the vaccine. The vaccine is provided by the government in response to the public health emergency (PHE). So, you have an item that is “free/no cost” and an administration service that is not free as there is cost related to the resources required to administer the vaccine. CMS will accept claims with only the administration service on the claim. However, they have recognized that some providers’ internal systems require a line item for a drug when there is an administration service billed. CMS confirmed that the product may be billed as a non-covered item with a minimal charge in order to satisfy a provider’s internal system requirements. This has been discussed on several CMS After Hours calls and is addressed in the COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing document. 

But what about other payers? Many non-Medicare payers have specific requirements for reporting services. This is not a new concept but can represent a challenge. What is consistent with Medicare is that payers must cover the vaccine and reimburse for the administration service.  

For coverage information and guidance on what CMS expects from commercial insurers and Medicare Advantage plans, please refer to the Toolkit on COVID-19 Vaccine: Health Insurance Issuers and Medicare Advantage Plans.

We know that reporting services can be payer situational. Part of the challenge may be that there should be a conversation with the individual payer if their requirements are not stated in their documentation. Consider the following questions:

  1. Does the payer require a line item representing the vaccine in order to process the claim?
  2. How do they want a free vaccine but a cost for administration billed?
  3. What does the payer website provide in terms of billing guidance for COVID-19 vaccine administration?

It is important to note that private, commercial, and managed care payers could have different requirements for billing for COVID-19 services, so you should seek out guidance from the specific payer in question.  

About the committee: The NAHRI Professional Advocacy Committee is responsible for the research and development of position papers that can help further the revenue integrity profession and bring awareness to matters impacting revenue integrity practices.