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. 

You can’t:

• 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: 

To Administer COVID-19 Vaccines?

How Do I Bill for Administering COVID-19 Vaccines?

Get the most current list of billing codes, payment allowances, and effective dates.

• 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 
• If you administer booster or pediatric doses, bill the appropriate billing code for administering these doses consistent with the FDA's updated EUAs.
• When the government provides COVID-19 vaccines at no cost, only bill for the vaccine administration. Don’t include the vaccine codes on the claim when the vaccines are free.
  • 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.
• If you had temporary billing privileges during the PHE, and you had 1 NPI tied to multiple Provider Transaction Access Numbers (PTANs), use the taxonomy code on your claim to help you assign the correct PTAN.
• Use the ICD-10 diagnosis code Z23 (encounter for immunization) on the claim.
• For dates of service through May 11, 2023, include modifier CR on your claim only if you administered the COVID-19 vaccine at a temporary location that wasn’t considered your actual practice location. In general, providers should only report the CR modifier during a PHE when a formal waiver is in place. So, you shouldn’t use it for most claims with dates of service on or after May 12, 2023. However, you should continue to use the CR modifier and COVID-19 narrative on claims for supplies and accessories associated with certain DMEPOS items provided during the PHE.

For the Additional Payment for Administering the Vaccine in the Patient’s Home?

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

Get the most current list of billing codes, payment allowances, and effective dates.

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
• Only bill for the additional in-home payment amount if the sole purpose of the visit is to administer a COVID-19 vaccine. Don't bill for the additional amount if you provide and bill Medicare for another service in the same home on the same date.
• For dates of service starting January 1, 2024, you should bill for the additional payment amount (approximately $38 in CY 2024) only once per patient per date of service in that home, even if you administer other Part B preventive vaccines (flu, hepatitis B, or pneumococcal). For example, if you give a COVID-19 shot and a flu shot to a patient in 1 home visit, we only pay 1 in-home additional payment. We’ll still pay the administration fee (approximately $40 for the COVID-19 vaccine in CY 2024) for every vaccine dose you give.
• Starting August 24, 2021, Medicare pays the additional payment amount (approximately $38 per dose administered for CY 2024) for up to a maximum of 5 vaccine administration services per home unit or communal space within a single group living location.
  • 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.
• For dates of service from June 8, 2021 – August 23, 2021, you should bill for the additional payment amount of approximately $35 only once per date of service in that home regardless of how many Medicare patients got the vaccine.
• If you submit roster bills for administering the COVID-19 vaccine in the home, you must submit 2 roster bills:
  • 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
• You may submit a single set of roster bills (one containing 90480 and another containing M0201) for multiple Medicare patients who get the COVID-19 vaccine in their individual units of a multi-unit living arrangement. Effective August 24, 2021, when you vaccinate fewer than 10 Medicare patients on the same date at the same group living setting, you may submit a roster bill for M0201 for up to a maximum of 5 Medicare patients in the same home, including for multiple Medicare patients vaccinated in a communal space of the multi-unit living arrangement.

Examples: 

Date COVID-19 Vaccines Administered (All on the Same Date)	Number of Patients Who Got the Vaccine	Medicare Pays  (Approximately)	Example Calculations (Approximate)
June 8, 2021 - August 23, 2021	2 patients in the same home	$115	$35 in-home additional payment + (2 x $40 for each COVID-19 vaccine dose) = $115
Starting August 24, 2021	2 patients in the same home	$156	(2 x $38 in-home additional payment) + (2 x $40 for each COVID -19 vaccine dose) = $156
	9 patients in the same home1	$550	(5 x $38 in-home additional payment) + (9 x $40 for each COVID -19 vaccine dose) = $550
	12 patients in the same home2	$518	(1 x $38 in-home additional payment)3 + (12 x $40 for each COVID -19 vaccine dose) = $518
	12 patients in 12 different homes4	$936	(12 x $38 in-home additional payment) + (12 x $40) = $936
	5 patients in a communal space in a group living setting and 3 patients in their individual rooms	$624	(5 x each COVID -19 vaccine dose $38 in-home additional payment for the single communal space) + (3 x $38 in-home additional payment for each of the individual homes) + (8 x $40 for each COVID -19 vaccine dose) = $624

¹Includes a communal space in a group living situation
²Could be an individual living unit or a communal space in a group living situation
³You 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
⁴In 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

If I’m a Rural Health Clinic or Federally Qualified Health Center?

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

For Medicare Patients with Part A Only & Other Types of Insurance Coverage?

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.

For Patients Who Don’t Have Medicare?

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)

Professional

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?

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.