CMS issues Billing Codes for Administration of 3rd Dose of COVID-19 Vaccines (Pfizer and Moderna) 8/17/21

On August 16, 2021, CMS issued a special bulletin:

Effective August 12, 2021, CMS will pay to administer additional doses of COVID-19 vaccines consistent with the FDA EUAs, using CPT code 0003A for the Pfizer vaccine and CPT code 0013A for the Moderna vaccine. A table of all current COVID-19 vaccines and monoclonal antibody codes is available at this link. CMS will pay the same amount to administer this additional dose as they did for other doses of the COVID-19 vaccine (approximately $40 each (subject to site of care and geographic adjustments)). CMS continues to make it clear to private insurers and Medicaid programs that they are responsible to cover these products and administration services at no charge to beneficiaries.

Please note: CMS will need to complete claims system updates in order to process and pay these new codes appropriately which they anticipate will be no later than August 27. CMS will hold, and then process all claims with these codes after they complete claims system updates. There are no changes in the CPT codes to report the vaccine products; these new codes are for the administration of the vaccine.

The Centers for Disease Control and Prevention updated their website on August 16, 2021 to provide guidance on COVID-19 Vaccines for Moderately to Severely Immunocompromised People. Currently CDC is recommending that the following populations receive an additional dose:

• Been receiving active cancer treatment for tumors or cancers of the blood

• Received an organ transplant and are taking medicine to suppress the immune system

• Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system

• Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)

• Advanced or untreated HIV infection

• Active treatment with high-dose corticosteroids or other drugs that may suppress the immune response

Although a physician’s order is not required to obtain the 3rd dose of the COVID-19 vaccine, the CDC recommends that individuals should talk with their healthcare provider about their medical condition, and whether getting an additional dose is appropriate for them.

SHOUT-OUTS

1. Pharmacy and Billing IT Systems should be updated with the appropriate HCPCS codes to bill for the administration of the 3rd dose of COVID-19 vaccines as specified in the newly revised Emergency Use Authorizations (EUA) for the Pfizer and Moderna vaccines.

2. Prescribers ordering COVID-19 vaccines should indicate if the dose is a 3rd dose of Pfizer or Moderna vaccine to ensure that the correct billing code is reported on the claim.

3. CDC is sponsoring an informational webinar on August 17 at 2PM ET. Registration is at this link.

4. Providers should know the distinction between an “additional dose” and a “booster dose”. 

Additional dose vs booster dose definition:

1. Additional dose: administration of an additional vaccine dose when the initial immune response following a primary vaccine series is likely to be insufficient. 

2. Booster dose: a dose of vaccine when the initial sufficient immune response to a primary vaccine series is likely to have waned over time. The need for and timing of a COVID-19 booster dose has not been established.