The purpose of this communication is to provide notice regarding information and procedure codes related to the coverage of SARS-CoV-2 (Coronavirus Disease 2019 (COVID-19)) vaccines and administration of the vaccines for Medicare Advantage members.
This policy communication addressing COVID-19 vaccine for Medicare Advantage members shall remain in effect through the end of the Public Health Emergency.
Effective January 1, 2022, this policy communication addressing COVID-19 vaccine for Medicare Advantage members has been updated to indicate the following:
- Claims for administration of COVID-19 vaccine should be submitted to the Medicare Advantage plan
- The administration of COVID-19 vaccine is a preventive service.
There is currently an outbreak of respiratory disease caused by a novel coronavirus, which has been detected both nationally and internationally. The virus has been named “SARS-CoV-2" and the disease it causes has been named “Coronavirus Disease 2019" (COVID-19).
Several pharmaceutical companies have developed vaccines that have shown efficacy in the prevention of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Distribution of COVID-19 vaccine will be controlled by the U.S. Government, which will collaborate with local and state governments. COVID-19 vaccine will initially be distributed to health care providers at no charge.
The administration of COVID-19 vaccine including additional doses are eligible for reimbursement consideration as a preventive service when the U.S. Food and Drug Administration (FDA) approval or FDA Emergency Use Authorization (EUA) criteria for the COVID-19 vaccine are met and the administration is in accordance with the Centers for Disease Control and Prevention (CDC) guidance.
A home visit for the sole purpose of administration of COVID-19 vaccine may be appropriate for individuals who meet either of the following criteria:
The individual has difficulty leaving the home to get the vaccine, which could mean any of these:
A condition, due to an illness or injury, that restricts their ability to leave home without a supportive device or help from a paid or unpaid caregiver
A condition that makes them more susceptible to contracting a pandemic disease like COVID-19
Generally unable to leave the home, and if they do leave home it requires a considerable and taxing effort
The individual is hard-to-reach because they have a disability or face clinical, socioeconomic, or geographical barriers to getting a COVID-19 vaccine in settings other than their home. These individuals face challenges that significantly reduce their ability to get vaccinated outside the home, such as challenges with transportation, communication, or caregiving.
For individuals currently receiving home care services, administration of COVID-19 vaccine is not eligible for separate reimbursement consideration from the home care visit.
According to the Centers for Disease Control and Prevention (CDC), the COVID-19 vaccine will be distributed at no charge. Therefore, additional reimbursement for the COVID-19 vaccine will not be provided by the Company.
The individual's medical record must reflect that the care provided is according to the pertinent FDA EUAs criteria and requirements. These medical records may include, but are not limited to, records from the professional providers' office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation must be made available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
CURRENT PROCEDURAL TERMI NOLOGY (CPT) CODES
NOT ELIGIBLE FOR REIMBURSEMENT
HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODES
M0201 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