Attention: Providers (Physicians, Physician’s Assistants, & Nurse Practitioners), Pharmacies and Local Health Departments Moderna COVID-19 Vaccine (N/A) HCPCS code 91301: Billing Guidelines

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

The following information is only for non-Long Term Care providers who have the means to handle the specific storage recommendations required of the Moderna COVID-19 vaccine and will be administering it. 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.  

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: 91301 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use
  • One Medicaid and NC Health Choice unit of coverage is: 0.5 mL 
  • The maximum reimbursement rate per unit is: N/A
  • Providers must bill 11-digit NDCs: unknown
  • 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).
link.zoom