Medicare Billing for COVID-19 Vaccine Shot Administration

Review information about Medicare billing for administering COVID-19 vaccines during and after the PHE.

There’s No Out-of-Pocket Cost for Your Patients

Patients can get the COVID-19 vaccine, including additional doses and booster doses, without a physician’s order or supervision, and they pay nothing for the vaccine and its administration.

• Charge your patients a copay, coinsurance, or deductible for the vaccine or administration of the vaccine
• Balance bill for COVID-19 vaccinations
• Charge your patients for an office visit or other fee if COVID-19 vaccination is the only medical service given
• Require additional medical or other services during the visit as a condition for getting a COVID-19 vaccination

Report any potential violations of these requirements to the HHS Office of Inspector General:

• Call 1-800-HHS-TIPS
• Submit an online complaint

Effective January 1 of the year following the year in which the EUA declaration for COVID-19 drugs and biologicals ends, we’ll cover and pay for administering COVID-19 vaccines to align with Medicare coverage and payment of other Part B preventive vaccines. Your patients pay nothing if you accept assignment. The EUA declaration is distinct from, and not dependent on, the PHE for COVID-19. Learn more about what happens to EUAs when a PHE ends.

How Do I Bill:

How Do I Bill for Administering COVID-19 Vaccines?

• You must be a Medicare-enrolled provider to bill Medicare for administering COVID-19 vaccines to Medicare patients.
• 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 (for example, in the medical record) your patient’s self-reported qualifying conditions for the additional dose
  • Bill the appropriate billing code for administering an additional dose
  • 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.

  How Do I Bill for the Additional Payment for Administering the Vaccine in the Patient’s Home?

  In addition to the requirements listed above, you must meet several other requirements to bill for the additional in-home payment amount for administering the COVID-19 vaccine to a Medicare patient:

  • You must use both:
    • CPT code for the COVID-19 vaccine administration (90480)
    • HCPCS Level II code M0201 to bill for the additional payment amount for administering the COVID-19 vaccine in the home
    • You can bill for up to 5 vaccine administration services only when fewer than 10 Medicare patients get a vaccine dose on the same day at the same group living location
    • When 10 or more Medicare patients get a vaccine dose at a group living location on the same day, you can only bill for the additional payment once per home (whether the home is an individual living unit or a communal space)
      • Bill the HCPCS Level II code (M0201) only 1 time for the additional payment rate if the date of service is between June 8, 2021 – August 24, 2021. For dates of service on or after August 24, 2021, if you administer the vaccine to fewer than 10 Medicare patients at the same group living location on that date, report the HCPCS Level II code M0201 for each Medicare patient you vaccinate in an individual home that day, and up to a maximum of 5 times if you vaccinate multiple Medicare patients in the same home or communal space.
      • Bill for each dose you administer using the appropriate CPT code for the product- and dose-specific COVID-19 vaccine administration.
      • Roster bill containing the CPT code for the COVID-19 vaccine administration (90480)
      • Second roster bill containing the HCPCS Level II code (M0201) for the additional in-home payment amount

      Examples:

      June 8, 2021 - August 23, 2021

      Starting August 24, 2021

      1 Includes a communal space in a group living situation
      2 Could be an individual living unit or a communal space in a group living situation
      3 You can only bill for 1 home add-on payment in this situation because you vaccinated 10 or more Medicare patients at the same group living location on the same date
      4 In other words, each vaccine administered in a distinct individual living unit or communal space of a group living situation

      For Medicare Advantage Patients?

      How Do I Bill for Medicare Advantage Patients?

      Submit COVID-19 vaccine administration claims to the Medicare Advantage Plan. Original Medicare won’t pay these claims.

      For Hospice Patients?

      How Do I Bill for Hospice Patients?

      For hospice patients under Part B only, you must include the GW modifier on COVID-19 vaccine administration claims if either of these apply:

      • The vaccine isn’t related to your patient’s terminal condition
      • The attending physician administered the vaccine

      Billing for Rural Health Clinics & Federally Qualified Health Centers

      For Original Medicare patients, Medicare pays Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for administering COVID-19 vaccines at 100% of reasonable cost through the cost report.

      For Medicare Advantage (MA) patients, RHCs and FQHCs should submit COVID-19 vaccine administration claims to the MA Plan. Original Medicare won’t pay these claims. To learn more about billing and payment, including MA wrap-around payments, visit the FQHC Center or review our FAQs (PDF).

      When Medicare is a Secondary Payer (Coordination of Benefits)?

      Coordination of Benefits & Medicare as Secondary Payer

      Before you submit a Medicare claim for administering COVID-19 vaccines, you must find out if:

      • Your Medicare patients have other insurance, such as employer health insurance or coverage through a spouse’s employer health insurance
      • Medicare pays first or second

      You must gather information both from patients with Original Medicare and those enrolled in Medicare Advantage plans. Verify the insurance information:

      • Ask your patients Medicare Secondary Payer questions (PDF)
      • Use an online tool or service (PDF) to find your patients’ information, and ask them to confirm the information

      Medicare & Other Types of Insurance Coverage

      • If your patients only have Part A Medicare coverage, ask if they have other medical insurance to cover Part B services, like vaccine administration.
      • If so, submit your COVID-19 vaccine administration claims to the insurance company. See toolkit (PDF) for more information.

      What if My Patients Don’t Have Medicare?

      • If you have questions about billing or payment for administering the vaccine to patients with private insurance or Medicaid, contact the health plan or state Medicaid agency
      • Patients without health insurance may be able to get the COVID-19 vaccine through their state or local health departments.

      How to Submit Claims

      Institutional

      How to Submit Institutional Claims

      You may use roster billing format, or submit individual claims. CMS systems will accept roster bills for 1 or more patients that get the same type of shot on the same date of service.

      What Are Valid Types of Bills for Roster Billing?

      • 12X, Hospital Inpatient**
      • 13X, Hospital Outpatient**
      • 22X, Skilled Nursing Facility (SNF)-covered Part A stay (paid under Part B) & Inpatient Part B
      • 23X, SNF Outpatient
      • 34X, Home Health (Part B Only)
      • 72X, Independent and Hospital-based Renal Dialysis Facility
      • 75X, Comprehensive Outpatient Rehabilitation Facility
      • 81X, Hospice (Nonhospital-based)
      • 82X, Hospice (Hospital-based)
      • 85X, Critical Access Hospital

      ** For hospitalized patients, Medicare pays for the COVID-19 vaccines separately from the Diagnosis-Related Group (DRG) rate. In addition, hospitals don't bill vaccines on an 11X type of bill. Hospitals bill on a 12X type of bill.

      How Do I Submit an Institutional Claim?

      Electronic Claims

      Use Direct Data Entry:

      1. Option 02, Claims Attachment
      2. Option 87, Roster Bill Entry

      Paper Claims

      1. CMS-1450 (UB-04)
      2. Roster bill for patients (find your MAC's website to learn more about or set up roster billing)

      How to Submit Professional Claims

      You may use 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.

      How Do I Submit a Professional Claim?

      Electronic Claims

      Download and use free PC-ACE billing software (PDF) to electronically submit professional claim roster billing directly to your MAC.

      Paper Claims

      1. Health Insurance Claim Form (CMS-1500) (PDF)
      2. Roster bill for patients (find your MAC website to learn more about or set up roster billing)

      What if I’m a Mass Immunizer?

      Mass immunizers may use a roster bill or submit a traditional claim form, such as a 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.

      What if I’m a Centralized Biller?

      How to Submit a Centralized Bill

      Providers enrolled as centralized billers can submit a professional claim to Novitas, regardless of where you administered the vaccines.

      You must operate in at least 3 MAC jurisdictions.