Attention: Providers (Physicians, Physician’s Assistants, & Nurse Practitioners), Pharmacies and Local Health Departments PFIZER-BioNTech COVID-19 Vaccine (N/A) HCPCS code 91300: Billing Guidelines

(this information is for the Pfizer COVID-19 vaccine only)

This is the first general communication regarding the COVID-19 vaccine. Medicaid will issue subsequent information related to the guidance of specific vaccination programs and/or specific FDA approved vaccines as information becomes available.  

Effective with date of service Dec 12, 2020, the Medicaid and NC Health Choice programs cover Pfizer-BioNTech COVID-19 Vaccine for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 91300 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use.

Strength/Package Size(s): Injection: Pfizer-BioNTech COVID-19 Vaccine is a preservative-free, frozen suspension for injection in a multiple dose vial.

Pfizer-BioNTech COVID-19 Vaccine is authorized for use under an Emergency Use Authorization (EUA) for active immunization to prevent coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in individuals 16 years of age and older.

Recommended Dose:  

  • The Pfizer-BioNTech COVID-19 Vaccine is administered intramuscularly as a series of two doses (0.3 mL each) three weeks apart.
  • Individuals who have received one dose of Pfizer-BioNTech COVID-19 Vaccine should receive a second dose of Pfizer-BioNTech COVID-19 Vaccine to complete the vaccination series.  
    • Vaccine products from different manufacturers are not interchangeable. 

The CDC has released Interim Guidance for Immunization Services During the COVID-19 Pandemic. This guidance is intended to help immunization providers in a variety of clinical and alternative settings with the safe administration of vaccines during the COVID-19 pandemic.

If you have any questions about product specific information, please contact the Immunization Branch Help Desk at 1-877-873-6247 and press option 6. If you have any questions about billing NC Medicaid, please call the NCTracks Call Center at 1-800-688-6696.

 

For Medicaid and NC Health Choice Billing

  • The ICD-10-CM diagnosis code required for billing is: Z23 - Encounter for immunization
  • Providers must bill with HCPCS code: 91300 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use
  • One Medicaid and NC Health Choice unit of coverage is: 0.3 mL 
  • The maximum reimbursement rate per unit is: N/A
  • Providers must bill 11-digit NDCs: 59267-1000-01, 59267-1000-02, 59267-1000-03
  • The NDC units should be reported as "UN1"
  • The fee schedule for the PADP is available on Medicaid's PADP web page

Important Claims Information:

  • Medicaid and NC Health Choice will reimburse at the Medicare approved COVID-19 vaccination administration rate at 1st dose $16.94 and 2nd dose $28.39
  • Claims must have appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code 
  • Claims must contain both administration codes and vaccine codes to pay
  • Vaccine codes should be reported as $0.00
  • Claims for 1st vaccine dose must have been processed in NCTracks prior to processing a claim for 2nd dose  
  • Medicaid and NC Health Choice does not allow copays to be charged for COVID-19 immunization or administrations
  • COVID-19 vaccines are exempt from the Vaccines For Children (VFC) program
  • TJ modifier should be used for NC Health Choice claims (age 6 through 18 years)
  • EP modifier should be used for all non-NC Health Choice (only Medicaid beneficiaries) younger than 21 years of age
  • CG modifier should be used for claims submitted by a pharmacy participating in the immunization program for both the vaccine and administration codes (EXCEPTION - CVS/Walgreens pharmacies participating in the Long-Term Care immunization program for beneficiaries residing at the participating LTC facility).
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