CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy | COVID-19 Vaccinations

Governs BCBSRI coverage, cost-share waiver, coding and billing rules for FDA-approved COVID-19 vaccines and associated administration services for participating and non-participating providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy | COVID-19 Vaccinations

Policy CodePolicy N/A

Change TypeNo material change (informational update only)

Effective Date12/11/2020

Next Review DateN/A

Key ActionWhen filing HCPCS M0201 for in‑home COVID-19 vaccine administration, also submit the appropriate vaccine CPT and dose‑specific administration CPT codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12/11/2020Policy effective date (initial EUA coverage)

10/05/2021Policy last updated

up to 5Max in‑home administrations

Z23Acceptable ICD‑10

No reimbursementNo reimbursement (some supplied vaccines)

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Coverage and Reimbursement Criteria

Coverage of FDA-approved COVID-19 vaccines and administration

Covered when ALL of the following are met:

FDA-approved COVID-19 vaccines are covered when recommended by CDC and AAP and when FDA guidelines are met.

Third doses and booster doses are covered when their use/administration is supported by federal, state and/or local guidelines and/or established and accepted standard of care practice.

Pfizer-BioNTech / Comirnaty: Pfizer-BioNTech (Comirnaty) is covered per EUA/approval for authorized age groups; EUA amendments permitting additional doses and single booster doses (per FDA dates cited) are recognized by this policy.

Moderna COVID-19 Vaccine is covered under EUA for authorized ages; FDA amendment permitting an additional dose for certain immunocompromised individuals is recognized.

Janssen (Johnson & Johnson): Janssen COVID-19 Vaccine is covered under EUA for authorized ages; EUA amendments noting rare clotting risk are acknowledged. At the time of this document, insufficient data supported an additional mRNA-type dose after single-dose Janssen in immunocompromised people.

In‑home administration: In‑home vaccine administration is covered; billing and reporting rules vary by date of service and number vaccinated at the same location (see billing rules).

Medicare Advantage billing direction: For Medicare Advantage enrollees, vaccine product and administration codes must be submitted to Original Medicare per CMS billing guidelines; do not bill BCBSRI for Medicare Advantage vaccine services.

E/M services and modifier 25: Evaluation and management (E/M) services should not be billed with vaccine administration unless a separately identifiable E/M service is performed and modifier 25 is appended with supporting documentation.

Coverage criteria and billing rules

Coverage and reimbursement rules:

Vaccine products supplied to providers at no cost: if a provider submits a claim for the vaccine product, no reimbursement will be made and the claim will indicate a denial for the vaccine.

For Commercial products, many administration CPT/HCPCS codes (dose‑specific administration codes) are covered and separately reimbursed when billed to BCBSRI.

For Medicare Advantage plans, many vaccine product and administration codes must be submitted to Original Medicare per CMS billing guidelines; do not bill BCBSRI for those Medicare Advantage vaccine services.

Providers filing HCPCS code M0201 for in‑home COVID‑19 vaccine administration must also file the appropriate vaccine product CPT code and the dose‑specific administration CPT code; M0201 is reported once per individual home per date of service when only COVID‑19 vaccine administration is performed.

Some vaccine product and administration codes and associated statuses in this document are noted as pending EUA or subject to FDA authorization status changes; coverage/reimbursement follows applicable FDA/CDC guidance and documented product availability.

Coding, Billing, and Limits

ICD-10ICD-10Covered

Z23	Encounter for immunization

Acceptable diagnosis codeICD-10

Z23	Encounter for immunization

Vaccine product and administration codes referencedCPT

91300	Pfizer-BioNTech COVID-19 Vaccine (mRNA-LNP), 30 mcg/0.3 mL
OO01A	Immunization administration by intramuscular injection; first dose (Pfizer)
OO02A	Immunization administration by intramuscular injection; second dose (Pfizer) - note: listed as OOOZA/OOOZA variants in doc
91301	Moderna COVID-19 Vaccine (mRNA-LNP)
91303	Janssen (Ad26) COVID-19 Vaccine
91304	Novavax COVID-19 Vaccine (recombinant spike protein nanoparticle)
91305	Pfizer tris-sucrose formulation (pending)
91306	Moderna pending EUA formulation

In‑home administration billing limits

Effective date and scopeFor dates of service on or after 2021-08-24: in‑home administration can be billed for up to a maximum of 5 vaccine administration services per home unit or communal space within a single group location when fewer than 10 Medicare members receive a COVID‑19 vaccine dose at the same group living location.

Single‑home rule (prior to 8/24/2021)For dates of service between 06/08/2021 and 08/24/2021, in‑home administration billed once per home per date of service.

Multiple members in same home (≤9 members)If COVID‑19 vaccine is administered to 9 members in the same home on the same date, up to 5 in‑home administrations are eligible for reimbursement (communal space limit applies).

Multiple members in same home (≥10 members)If 10 or more members are vaccinated at the same location on the same date, only one in‑home administration is billable for that location on that date.

Combination communal + individual roomsExample: 5 administrations billed for a communal space plus 3 administrations for individual rooms (total 8) — all 8 are eligible if total does not exceed rules stated (communal limit plus individual rooms).

Medicare vs Commercial billing direction

Medicare Advantage billing directionFor many vaccine product and administration codes for Medicare Advantage enrollees, submit claims to Original Medicare per CMS billing guidelines; do not bill BCBSRI for these services.

Commercial product billingFor Commercial Products many dose‑specific administration codes are covered and separately reimbursed by BCBSRI (or noted as no reimbursement when vaccine supplied to provider at no cost).

No reimbursement when vaccine supplied at no costVaccine products that health care providers receive at no cost: no reimbursement for claims submitted to BCBSRI for the vaccine product.

Code‑level direction present in policyPolicy lists specific vaccine product and administration CPT/HCPCS codes with Medicare vs Commercial billing instructions (see coding tables).

Provider Requirements and Filing Instructions

Prior Authorization

Prior authorization is not required for COVID-19 vaccination or administration services.

Documentation Required

Documentation / Audit

BCBSRI may perform routine reviews and audits of submitted claims for compliance with this policy, correct coding, and other BCBSRI policies. Providers must maintain and make available documentation supporting billed services. Failure to provide requested documentation in a timely manner may result in denial or retraction of payment.

Do not bill an E/M code (e.g., 99211) when the sole intent of the visit is vaccine administration.
If an Evaluation & Management (E/M) service is separately identifiable, append modifier 25 and ensure documentation supports the distinct service; documentation must be provided upon request.

Billing Rule

Billing direction for Medicare Advantage

For Medicare Advantage enrollees, COVID-19 vaccine product and administration codes must be submitted to Original Medicare per CMS guidelines. Providers should not bill BCBSRI for services for members enrolled in Medicare Advantage when CMS directs submission to Original Medicare.

Submit vaccine product and administration codes to Original Medicare for Medicare Advantage members (per CMS guidance).
Do not bill BCBSRI for Medicare Advantage vaccine or administration services.

Billing Rule

In-home administration filing requirements

When billing HCPCS code M0201 for in-home COVID-19 vaccine administration, providers must also file the vaccine product CPT code and the dose-specific CPT administration code on the same claim, and follow BCBSRI rules about when in-home administration may be billed (see policy guidelines). In-home administration billing limits apply based on date of service and number of members vaccinated at the same location.

File the appropriate CPT code for the specific vaccine product (dose-specific vaccine CPT/NDC as applicable).
File the appropriate CPT code for the dose-specific COVID-19 vaccine administration.
File HCPCS code M0201 to identify that the vaccine was administered in the home.
In-home administration should be billed only when the sole purpose of the visit is vaccine administration; if other services are provided during the same visit, do not bill M0201.
For dates of service June 8, 2021 through August 24, 2021: M0201 may be reported once per home per date of service.
For dates of service on or after August 24, 2021: up to 5 in-home administration services per home unit or communal space may be billed when fewer than 10 Medicare members receive a COVID-19 vaccine dose at the same group living location; if 10 or more members are vaccinated at the same location on the same date, only one in-home administration is billable for that circumstance.
Examples: If 9 members at a group living location are vaccinated on the same date, up to 5 in-home administrations are reimbursable; if 12 members are vaccinated at the same location on the same date, only 1 in-home administration is billable; if 5 are vaccinated in a communal space and 3 in individual rooms, all 8 administrations are eligible (5 communal + 3 individual).

Definitions and Policy Notes

Cost share waiver for FDA‑approved COVID‑19 vaccines

Policy scopeBCBSRI coverage of and cost share waiver for FDA‑approved COVID‑19 vaccines and associated administration services for participating and non‑participating providers.

Applies to providersThis policy applies to BCBSRI participating providers as well as non‑participating or Out‑of‑Network providers with BCBSRI.

BCBSRI change authorityBCBSRI reserves the right to implement changes to this policy without the normal 60‑day provider notification due to the urgent nature of a pandemic service.

Modifier 25 guidance

When to append Modifier 25Append modifier 25 to an E/M code when the E/M represents a separately identifiable, significant service in addition to vaccine administration and documentation supports the distinct service.

Documentation requirementSubmission of modifier 25 indicates documentation exists in the patient record to support the distinct E/M; records must be provided timely upon request.

Do not file routine E/M for vaccine visitIt is incorrect to file E/M codes (e.g., 99211) when the sole intent of the visit is COVID‑19 vaccination; vaccine administration CPT includes counseling and observation time per AMA CPT guidance.

Encounter for immunization

ICD‑10 code for immunization encountersZ23 — Encounter for immunization.

Reporting guidanceProviders should report the most appropriate ICD‑10 diagnostic code(s) for any patient encounter; Z23 is acceptable for COVID‑19 vaccine administration.

ApplicabilityZ23 is listed in the policy as the acceptable diagnosis code when reporting COVID‑19 vaccine administration encounters.

HCPCS code identifying in‑home COVID‑19 vaccine administration (M0201)

HCPCS code for in‑home COVID‑19 vaccine administrationM0201 — COVID‑19 vaccine administration inside a patient's home; reported only once per individual home, per date of service, when only COVID‑19 vaccine administration is performed at the patient's home.

Filing requirements with M0201When filing M0201, providers must also file the appropriate CPT code for the vaccine product and the dose‑specific administration CPT code.

Billing frequency ruleM0201 is reported once per individual home per date of service when only COVID‑19 vaccine administration is performed in the home; see policy statement for additional guidance on when filing is appropriate.