This guidance sets forth New York State (NYS) Medicaid’s reimbursement policy for the administration of COVID-19 vaccines authorized for emergency use and instructions for providers to bill the cost of administration of authorized COVID19 vaccine.
NYS Guidance found here
This coverage policy applies to both Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC).
Current billing guidance for administering the COVID vaccine for the NYS Hospital Outpatient clinics, D&TC’s and FQHC’s including NYS SBHC’s:
1) Reimbursement for administration of COVID-19 vaccines may be based on a patient-specific order or non-patient specific order (“standing order”). These orders must be kept on file by the provider.
2) Ordering provider’s National Provider Identifier (NPI) is required on the Medicaid claim.
3) Can’t charge a co-pay or any cost sharing.
4) Bill an Ordered Ambulatory Fee claim only for the administration with CPT codes below depending on vaccine brand: (Do not include a vaccine code or claim will deny.)
Pfizer 1st dose- bill CPT 0001A
Pfizer 2nd dose - CPT 0002A
Moderna 1st dose - CPT 0011A
Modera 2nd dose - CPT 0012A
Janssen - CPT 0013A
5) Current reimbursement post 4/1/2021: $40.00; Prior to 4/1/2021: $13.23
6) The COVID-19 vaccine administration CPT codes above include the actual work of administering the vaccine, including all necessary counseling provided to patients and/or caregivers, required vaccination reporting, and updating of electronic records.
7) If a separate and distinct E/M service is provided on same day, bill an APG or PPS claim for the E/M or other service(s). Still the administration to a separate Ordered Ambulatory Fee claim per above
See guidance for other rate-based providers, pharmacy and ambulance billing.