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Provider Coronavirus Information

The Department of Community Health (DCH) has received requests for additional clarification of the telehealth guidance released 3/17/20 and further clarified in a message dated 3/18/20. In response to requests for clarification of service delivery locations and the term “distant site locations” DCH is issuing additional guidance to clarify these outstanding questions.

Qualified Providers

Qualified providers permitted to furnish Medicaid-reimbursed telehealth services during the Public Health Emergency include physicians and certain non-physician providers such as nurse practitioners, physician assistants and certified nurse midwives. Other practitioners enrolled in Georgia Medicaid such as certified nurse anesthetists, licensed clinical social workers, clinical psychologists and therapists (PT, ST and OT) may also deliver services within their scope of practice, consistent with Medicaid reimbursement rules, and in the category of service in which they are enrolled.

Service Delivery Location: Originating Site

The Coronavirus Preparedness and Response Supplemental Appropriations Act as signed into law by the President on March 6, 2020 allows states broad authority to waive limitations on settings where members are eligible to receive telehealth and where telehealth services can be delivered during the emergency. All members with access to video or telephone communication may receive services in their homes to reduce exposure to themselves and others. Under the emergency declaration and waivers, these services may be provided by professionals regardless of patient location. The services must meet established medical necessity criteria relevant to the procedure or treatment.

Service Delivery Location: Distant Site

Qualified providers deliver services from distant sites. During the COVID-19 state of emergency, providers may deliver medically necessary services in various settings including their homes or other settings in which the privacy and confidentiality of the member can be assured. Qualified providers should continue to follow all applicable licensure rules specific to their profession. Services delivered from distant sites will be billed using the provider billing address associated with the enrolled Medicaid practice or facility. Claims must be billed using the associated procedure code, GT modifier and place of service code 02 to indicate telehealth delivery.

Billing

Providers should reference the 3/18/20 banner message relating to COVID-19 and the Use ofTelehealth for additional requirements related to member consent and patient confidentiality. DCH will continue to review all categories of service, adding services and procedure codes that can be reimbursed through telehealth service delivery as identified. MMIS will be modified to include new codes following DCH review. The Department will post additional information as needed.

Verbal Consent

Consent to receive services must be provided verbally by the member and noted in the member’s file or medical record. Providers are not required to obtain a hard copy of the consent form as noted in the Telehealth Guidance manual.

If you have questions related to the waiver of originating or distant site requirements, please contact the DXC Technology Provider Contact Center at 1-800-766-4456 and/or your assigned Provider DXC Representative.

We are closely monitoring and following all guidance from the Centers for Medicare and Medicaid as it is released to ensure we can quickly address and support the prevention, screening, and treatment of COVID-19. The following guidance can be used to bill for services related to COVID-19 testing, screening and treatment services. This guidance is in response to the current COVID-19 pandemic and may be retired at a future date. For additional information and guidance on COVID-19 billing and coding, please visit the resource centers of the Centers for Medicare and Medicaid (CMS) and the American Medical Association (AMA)

COVID-19 Testing Services

  • Providers performing the COVID-19 test can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
    • HCPCS U0001 - For CDC developed tests only - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
    • HCPCS U0002 - For all other commercially available tests - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
    • CPT 87635 - Effective March 13, 2020 and issued as “the industry standard for reporting of novel coronavirus tests across the nation’s health care system.”

Please note:  It is not yet clear if CMS will rescind the more general HCPCS Code U0002 for non-CDC laboratory tests that the Medicare claims processing system is scheduled to begin accepting starting April 1, 2020.

  • These codes should not be used for serologic tests that detect COVID-19 antibodies.
  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for any claim billed with the new COVID-19 testing codes.
  • We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these new COVID-19 testing codes.
  • In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • We will temporarily waive requirements that out-of-state Medicare and Medicaid providers be licensed in the state where they are providing services when they are licensed in another state.

High-Throughput Technology Testing Services

  • Providers performing high production COVID-19 diagnostic testing via high-throughput technology can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
    • HCPCS U0003 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
    • Please note: U0003 should identify tests that would otherwise be identified by CPT code 87635 but for being performed with these high throughput technologies.
    • HCPCS U0004 -2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.
    • Please note: U0004 should identify tests that would otherwise be identified by U0002 but for being performed with these high throughput technologies.
  • Neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.
  • We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these codes to indicate high production testing.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.

COVID-19 Specimen Transfers

  • For specimen transfer related claims, the following codes can be used:
    • G2023 - Spec Clct for SARS-COV-2 COVID 19 ANY SPEC SRC
    • G2024 - SP CLCT SARS-COV2 COVID19 FRM SNF/LAB ANY SPEC
    • C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source. This is effective for services provided on or after March 1, 2020.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.

COVID-19 Screening Services

  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for COVID-19 screening visits and if billed alongside a COVID-19 testing code.
  • If no testing is performed, providers may still bill for COVID-19 screening visits for suspected contact using the following Z codes:
    • Z20.828 – Contact with a (suspected) exposure to other viral communicable diseases
    • Z03.818 – Exposure to COVID-19 and the virus is ruled out after evaluation
  • This applies to services that occurred as of February 4, 2020.
  • Providers billing with these codes will not be limited by provider type.

COVID-19 Treatment Services

  • We will waive prior authorization requirements and member cost sharing for COVID-19 treatment for all members.
    • For dates of service from February 4, 2020 through March 31, 2020 providers should use the ICD-10 diagnosis code:
    • B97.29 – Confirmed Cases – other coronavirus as the cause of diseases classified elsewhere
  • For dates of service of April 1, 2020 and later, providers should use the ICD-10 diagnosis code:
    • U07.1 – 2019-nCov Confirmed by Lab Testing
  • As a reminder, only those services associated with screening and/or treatment for COVID-19 will be eligible for prior authorization and member liability waivers.  For screening or treatment not related to COVID-19 normal copayment, coinsurance, and deductibles will apply.

Reimbursement Rates for COVID-19 Services for All Provider Types

  • We are complying with the rates published by CMS for the following codes:
    • U0001 = $35.91
    • U0002 = $51.31
    • U0003 = $100.00
    • U0004 = $100.00
    • G2023 = $23.46
    • G2024 = $25.46
  • Commercial products will reimburse COVID-19 services in accordance with our negotiated commercial contract rates.
  • We will follow these CMS published rates except where state-specific Medicaid rate guidance should supersede.
  • Any additional rates will be determined by further CMS and/or state-specific guidance and communicated when available.

We are complying with the rates published on 3/12/20 by CMS:

  • U0001 = $35.91
  • U0002 = $51.31
  • Please note: Commercial products will reimburse COVID-19 testing services in accordance with our negotiated commercial contract rates.

Any additional rates will be determined by further CMS and/or state-specific guidance and communicated when available.

Coronavirus disease 2019 (COVID-19) is an emerging illness.  Many details about this disease are still unknown, such as treatment options, how the virus works, and the total impact of the illness.  New information, obtained daily, will further inform the risk assessment, treatment options and next steps.  We always rely on our provider partners to ensure the health of our members, and we want you to be aware of the tools available to help you identify the virus and care for your patients during this time of heightened concern.

Guidance

  • Know the warning signs of COVID-19. Patients with COVID-19 have reported mild to severe respiratory symptoms. Symptoms include fever, cough, and shortness of breath. Other symptoms include fatigue, sputum production, and muscle aches.  Some individuals have also experienced gastrointestinal symptoms, such as diarrhea and nausea, prior to developing respiratory symptoms.  
  • However, be aware that infected individuals can be contagious before symptoms arise. Symptoms may appear 2-14 days after exposure.
  • Instruct symptomatic patients to wear a surgical or isolation mask and promptly place the patient in a private room with the door closed.
  • Health care personnel encountering symptomatic patients should follow contact precautions, airborne with N95 precautions, and wear eye protection and other personal protective equipment.
  • Refer to the CDC’s criteria for a patient under investigation for COVID-19.  Notify local and/or state health departments in the event of a patient under investigation for COVID-19.  Maintain a log of all health care personnel who provide care to a patient under investigation.
  • Monitor and manage ill and exposed healthcare personnel.
  • Safely triage and manage patients with respiratory illness, including COVID-19.  Explore alternatives to face-to-face triage and visits as possible, and manage mildly ill COVID-19 cases at home, if possible.  

Take Action

  1. Be alert for patients who meet the criteria for persons under investigation and know how to coordinate laboratory testing.
  2. Review your infection prevention and control policies and CDC's recommendations  for healthcare facilities for COVID-19.
  3. Know how to report a potential COVID-19 case or exposure to facility infection control leads and public health officials.  Contact your local and/or state health department to notify necessary health officials in the event of a person under investigation for COVID-19.
  4. Refer to the Centers for Disease Control and Prevention (CDC) and the World Health Organization for the most up-to-date recommendations about COVID-19, including signs and symptoms, diagnostic testing, and treatment information.
  5. Be familiar with the intended scope of available testing and recommendations from the FDA.    

This guidance is in response to the current COVID-19 pandemic and may be retired at a future date.

Document Title: Medicaid Notice of COVID-19 Vaccine Billing Guidelines for                                                      Providers - Web

Point of Origin: Ann Meagle, Director, Provider Communications

Objective: Inform Medicaid and CHIP providers on upcoming billing guidelines for COVID-19 vaccine-related claims.

Intended Audience: All Medicaid and CHIP providers.

Format: Web posting for Provider Section of Health Plan public websites.

Requirement: Required.

Action Needed: Health Plan Provider Relations leads to work with Corporate/Plan Marketing and Web teams to post update on public websites.

THE CENTERS FOR MEDICARE AND MEDICAID (CMS) RELEASE BILLING GUIDELINES FOR COVID-19 Vaccine

Peach State Health Plan is closely following advancements in the prevention and treatment of COVID-19, including vaccinations. As a healthcare provider, you will play an integral role as COVID-19 vaccines become available. We want to update you on important new information about vaccine coverage.

To prepare for vaccine administration, the Centers for Medicare and Medicaid (CMS) have published billing guidance for Medicaid and Children’s Health Insurance Program (CHIP) providers.  Similar to other COVID-19 services, the vaccines will be offered at no cost to your patients. In addition:

  • Peach State Health Plan will configure its systems to properly adjudicate COVID-19 vaccine-related claims, both for the vaccine and its administration, in accordance with Georgia’s coverage determinations for Medicaid beneficiaries
  • Member liability will be $0
  • Non-participating provider pre-auth requirements will be waived
  • Provider reimbursement rates and emergency use authorizations (EUA) are all still pending and we will update you as that information becomes available

The American Medical Association (AMA) has published updates to the Current Procedural Terminology (CPT®) code set that includes new vaccine-specific codes to report immunizations for the novel coronavirus (SARS-CoV-2). The code set will continue to be updated as additional vaccines receive EUA approval by the U.S. Food & Drug Administration (FDA).

The following codes have been published as of November 10, 2020. However, they will not be billable until the specific vaccine receives official EUA approval.

Code

CPT Short Descriptor

Labeler Name

Vaccine/Procedure Name

91300

SARSCOV2 VAC

30MCG/0.3ML IM

Pfizer

Pfizer-Biotech Covid-19 Vaccine

0001A

ADM SARSCOV2 VAC

30MCG/0.3ML 1ST

Pfizer

Pfizer-Biotech Covid-19 Vaccine

Administration – First Dose

0002A

ADM SARSCOV2 VAC

30MCG/0.3ML 2ND

Pfizer

Pfizer-Biotech Covid-19 Vaccine

Administration – Second Dose

91301

SARSCOV2 VAC

100MCG/0.5ML IM

Moderna

Moderna Covid-19 Vaccine

0011A

ADM SARSCOV2 VAC

100MCG/0.5ML 1ST

Moderna

Moderna Covid-19 Vaccine

Administration – First Dose

0012A

ADM SARSCOV2 VAC

100MCG/0.5ML 2ND

Moderna

Moderna Covid-19 Vaccine

Administration – Second Dose

Additionally, CMS has also published a set of toolkits to help providers prepare to swiftly administer the vaccine once it is available. If you have any further questions about this upcoming vaccine or the COVID-19 services Peach State Health Plan covers, please contact Provider Services at 1-866-874-0633.

As we continue address the COVID-19 pandemic, we want to update you on important Medicare benefit information as it relates to currently expanded coverages. For dates of service June 1, 2021 onward, Medicare member liability (copayments, coinsurance and/or deductible cost sharing) will be reinstated as according to their benefits for the following services:

COVID-19 Treatment Services

  • COVID-19 treatment services (those billed with a confirmed ICD-10 diagnosis code) will continue to be eligible for coverage for the duration of the public health emergency (PHE).
  • Prior authorization requirements will also continue to be waived for COVID-19 treatment services during the PHE.
  • Providers should resume collecting Medicare member liability at the point of service on June 1, 2021 onward.

All Telehealth Services

  • Any services that can be delivered virtually will continue to be eligible for telehealth coverage for the duration of the public health emergency (PHE).
  • Prior authorization requirements will also continue to be waived for all telehealth services during the PHE.
  • Providers should resume collecting Medicare member liability at the point of service on June 1, 2021 onward.
  • Providers should reflect telehealth care on their claim form by following standard telehealth billing protocols in their state.
  • For further coding guidance for telehealth services, we recommend following what is being published by:

In accordance with this reinstatement, Allwell from Peach State Health Plan has updated the Billing Guidance for COVID-19 Vaccines, Testing, Screening, and Treatment document posted on our website.

Allwell from Peach State Health Plan continues to work in close partnership with state, local and federal authorities to serve and protect our members and communities during the COVID-19 pandemic, including ensuring that our providers have relevant and up-to-date information. We value your partnership during these unprecedented times.

This guidance is in response to the current COVID-19 pandemic and may be retired at a future date.

                          

We are closely monitoring and following all guidance from the Centers for Medicare and Medicaid as it is released to ensure we can quickly address and support the prevention, screening, and treatment of COVID-19. The following guidance can be used to bill for services related to COVID-19 vaccinations, testing, screening and treatment services. This guidance is in response to the current COVID-19 pandemic and may be retired at a future date. For additional information and guidance on COVID-19 billing and coding, please visit the resource centers of the Centers for Medicare and Medicaid (CMS) and the American Medical Association (AMA).  

COVID-19 Vaccines

  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for claims billed with the new COVID-19 vaccine codes.
  • In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes. This includes non-participating providers.
  • Per CMS guidance, all Medicare claims for the COVID-19 vaccine and its administration must be billed directly to Original Medicare fee-for-service (FFS).
  • All Medicare claims related to the COVID-19 vaccine codes will be denied, with direction to submit directly to Medicare FFS for payment.
  • The following codes have been published as of February 22, 2021. NOTE: Vaccines will not be billable until the specific vaccine receives official EUA approval. Currently approved vaccines are denoted by their effective date below.  

Code

CPT Short Descriptor

Labeler Name

Vaccine/Procedure Name

Effective Date

91300

SARSCOV2 VAC

30MCG/0.3ML IM

Pfizer

Pfizer-BioNTech Covid-19 Vaccine

12/11/2020

0001A

ADM SARSCOV2 VAC

30MCG/0.3ML 1ST

Pfizer

Pfizer-BioNTech Covid-19 Vaccine

Administration – First Dose

12/11/2020

0002A

ADM SARSCOV2 VAC

30MCG/0.3ML 2ND

Pfizer

Pfizer-BioNTech Covid-19 Vaccine

Administration – Second Dose

12/11/2020

91301

SARSCOV2 VAC

100MCG/0.5ML IM

Moderna

Moderna Covid-19 Vaccine

12/18/2020

0011A

ADM SARSCOV2 VAC

100MCG/0.5ML 1ST

Moderna

Moderna Covid-19 Vaccine

Administration – First Dose

12/18/2020

0012A

ADM SARSCOV2 VAC

100MCG/0.5ML 2ND

Moderna

Moderna Covid-19 Vaccine

Administration – Second Dose

12/18/2020

91303

SARSCOV2 VAC

AD26 .5ML IM

Janssen

Janssen Covid-19 Vaccine

2/22/2021

0031A

ADM SARSCOV2 VAC

AD26 .5ML

Janssen

Janssen Covid-19 Vaccine Administration

2/22/2021

 

  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 vaccine payments.

COVID-19 Testing Services

  • Providers performing the COVID-19 test can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
    • HCPCS U0001 - For CDC developed tests only - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
    • HCPCS U0002 - For all other commercially available tests - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
    • CPT 87635 - Effective March 13, 2020 and issued as “the industry standard for reporting of novel coronavirus tests across the nation’s health care system.”
    • PLA 0202U - Effective May 20, 2020. Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.

Please note:  It is not yet clear if CMS will rescind the more general HCPCS Code U0002 for non-CDC laboratory tests that the Medicare claims processing system is scheduled to begin accepting starting April 1, 2020.

  • These codes should not be used for serologic tests that detect COVID-19 antibodies.
  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for any claim billed with the new COVID-19 testing codes.
  • We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these new COVID-19 testing codes.
  • In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • We will temporarily waive requirements that out-of-state Medicare and Medicaid providers be licensed in the state where they are providing services when they are licensed in another state.
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 testing services payments.

COVID-19 Antigen Testing Services

  • Providers performing COVID-19 antigen tests can bill us for testing services that occurred after June 25, 2020, using the following HCPCS codes
    • 87426 - Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg SARS-CoV, SARA-CoV-2 (COVID-19).
    • 0223U - Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
    • 0224U - Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease (COVID-19) includes titer(s), when performed (Do not report 0224U in conjunction with 86769).
  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for any claim billed with the above COVID-19 antibody testing codes.
  • In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes. This includes non-participating providers.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 antigen testing services payments.

High-Throughput Technology Testing Services

  • Providers performing high production COVID-19 diagnostic testing via high-throughput technology can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
    • HCPCS U0003 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
    • Please note: U0003 should identify tests that would otherwise be identified by CPT code 87635 but for being performed with these high throughput technologies.
    • HCPCS U0004 -2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.
    • Please note: U0004 should identify tests that would otherwise be identified by U0002 but for being performed with these high throughput technologies.
  • Neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.
  • We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these codes to indicate high production testing.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 high-throughput technology services payments.

COVID-19 Specimen Transfers

  • For specimen transfer related claims, the following codes can be used:
    • G2023 - Spec Clct for SARS-COV-2 COVID 19 ANY SPEC SRC
    • G2024 - SP CLCT SARS-COV2 COVID19 FRM SNF/LAB ANY SPEC
    • C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source. This is effective for services provided on or after March 1, 2020.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 specimen transfer payments.

COVID-19 Screening Services

  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for COVID-19 screening visits and if billed alongside a COVID-19 testing code.
  • If no testing is performed, providers may still bill for COVID-19 screening visits for suspected contact using the following Z codes:
    • Z20.828 – Contact with a (suspected) exposure to other viral communicable diseases
    • Z03.818 – Exposure to COVID-19 and the virus is ruled out after evaluation
  • This applies to services that occurred as of February 4, 2020.
  • Providers billing with these codes will not be limited by provider type.
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 screening service payments.

COVID-19 Treatment Services

  • For dates of service of April 1, 2020 and later, providers should use the ICD-10 diagnosis code:
    • U07.1 – 2019-nCov Confirmed by Lab Testing
  • We will waive member cost sharing for COVID-19 treatment for all members for dates of service through May 31, 2021.
  • For dates of service June 1, 2021 and onward, providers should collect Medicare and Marketplace member cost share (copayment, coinsurance and/or deductible amounts) at the point of service.
  • Prior authorization requirements will continue to be waived for COVID-19 treatment services.

COVID-19 Monoclonal Antibody Infusion Services

  • All Marketplace and Medicaid member cost share (copayment, coinsurance and/or deductible amounts) will be waived for claims billed with the new COVID-19 monoclonal antibody infusion services codes.
  • In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes. This includes non-participating providers.
  • Per CMS guidance, all Medicare claims for monoclonal antibody infusion services must be billed directly to Original Medicare fee-for-service (FFS).
  • Medicare claims related to the monoclonal antibody infusion codes will be denied, with direction to submit directly to Medicare FFS for payment.
  • CMS has identified the following specific code(s) for the monoclonal antibody product and specific administration code(s) for Medicare payment:
    • Eli Lilly and Company’s Antibody Bamlanivimab (LY-CoV555), EUA effective November 9, 2020
      • Q0239 - Injection, bamlanivimab-xxxx, 700 mg
      • M0239 - Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring
    • Regeneron’s Antibody Casirvimab and Imdevimab (REGN10933 and REGN10987), EUA effective November 21, 2020
      • Q0243 – Injection, casirvimab and imdevimab, 2400 mg
      • M0243 – Intravenous infusion, casirvimab and imdevimab, includes infusion and post-administration monitoring
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 monoclonal antibody infusion service payments.

The Georgia Department of Public Health is prioritizing COVID vaccinations based on the risk of infection and transmission of COVID-19, and ethical considerations. The goal is for all Georgians to have access to COVID vaccine as soon as large enough quantities are available and allocated to Georgia by the federal government.

Among Georgia’s current eligible populations for vaccination are individuals aged 16 and older with disabilities and their caregivers, parents of children with complex medical conditions who are at high risk for COVID-19 complications and individuals with certain medical conditions as defined below.

Intellectual Disability is a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills. This disability originates before the age of 22.

Developmental disability is a physical or mental impairment that happens before the age of 22, is expected to last a lifetime, and impacts at least three activities of daily living. Activities of daily living include self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; and economic self-sufficiency.

Disabilities also include disabilities caused by an injury (e.g., traumatic brain injury or spinal cord injury), a disability due to a longstanding condition that could cause vision loss, nerve damage or loss of a limb, or a disability due to illness such as ALS or multiple sclerosis.

Caregivers provide care to people who need some degree of ongoing assistance with everyday tasks on a regular or daily basis. The recipients of care can live either in residential or institutional settings, range from children to older adults, and have chronic illnesses or disabling conditions.

Parents of children with complex medical conditions or who are at high risk for COVID-19 complications include:

  • Malignancies requiring active treatment
  • Immunocompromised state (weakened immune system) including organ transplant (bone marrow or solid organ) within 2 years
  • Critical congenital heart disease
  • Asthma (moderate to severe)
  • Sickle cell disease
  • Diabetes
  • Obesity
  • Cystic fibrosis
  • Significant neurologic injury or condition (e.g. hypoxic ischemic encephalopathy, traumatic brain injury, congenital anomaly, acute flaccid myelitis) with functional/developmental impairment (e.g. cerebral palsy, developmental disability, prematurity, mitochondrial disease)
  • Technology dependence (e.g. BiPAP, trach)
  • Individuals aged 16 and older with certain underlying medical conditions are at increased risk for severe illness from the virus that causes COVID-19. Severe illness from COVID-19 is defined as hospitalization, admission to the ICU, intubation or mechanical ventilation, or death. These conditions include:
  • Asthma (moderate to severe)
  • Cancer
  • Cerebrovascular disease (affects blood vessels and blood supply to the brain)
  • Chronic kidney disease
  • Chronic Obstructive Pulmonary Disease
  • Cystic Fibrosis
  • Diabetes
  • Hypertension or high blood pressure
  • Heart conditions
  • Immunocompromised (from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines)
  • Liver disease
  • Neurological conditions
  • Overweight and obesity (Having obesity, defined as a body mass index (BMI) between 30 kg/m2 and <40 kg/m2 or severe obesity (BMI of 40 kg/m2 or above), increases your risk of severe illness from COVID-19. Having overweight, defined as a BMI > 25 kg/m2 but less than 30 kg/m2 might increase your risk of severe illness from COVID-19.)
  • Pregnancy
  • Pulmonary fibrosis
  • Sickle Cell disease
  • Thalassemia (blood disorder)

Additional information about medical conditions.

NOTE: Pfizer is the only COVID vaccine currently approved for children aged 16 and older. Please schedule an appointment at CVS or Walgreens or at one of the GEMA mass vaccination sites to ensure Pfizer vaccine is available.

Source: Georgia Department of Public Health       

Answering Patient Questions about the Vaccine

Your patients will likely have a lot of questions about the vaccine, and as their healthcare provider, they will turn to you for answers.

Pharmacies are generally the most convenient locations to individuals and they also have great expertise in administering vaccines. While many providers anticipate to have the vaccine in their office later on, for now we recommend patients visit their local pharmacy. later on, for now we recommend patients visit their local pharmacy. The website https://dph.georgia.gov/locations/covid-vaccination-site can help them locate the closest location with current inventory.

Initially, there will be a limited number of vaccines available.  Because of the limited supply, some groups are recommended to get the vaccine first:

  • Phase 1A will include residents and employees of nursing homes and long-term care facilities.  They are recommended to get the vaccine first, as they are deemed highly vulnerable.  Long-term care facilities account for a high percentage of the deaths from COVID-19 (40%).
  • Additional phases are being developed by federal and state governments.  This will address first-responders, essential workers, older adults and people more at risk for either contracting the virus or becoming seriously ill with the virus.

The Food and Drug Administration (FDA) carefully reviews all safety data from clinical trials. It only authorizes emergency vaccine use when the expected vaccine benefits outweigh potential risks.

  • The Advisory Committee on Immunization Practices (ACIP) reviews all safety data before recommending any COVID-19 vaccine for use.
  • FDA and CDC will continue to monitor the safety of COVID-19 vaccines to make sure even very rare side effects are identified.

Explain the potential serious risk COVID-19 infection poses to them and their loved ones if they get the illness or spread it to others.

  • Remind them of the potential for long-term health issues after recovery from COVID-19 disease, especially for those who have chronic conditions, are older, or have weakened immune systems.
  • Explain that scientists are still learning more about the virus that causes COVID-19. And it is not known whether getting COVID-19 disease will protect everyone against getting it again, or, if it does, how long that protection might last. Therefore getting a vaccine is a safer choice.
  • Some vaccines are more effective than the natural illness; it is not clear whether natural illness or vaccination will provide more effective immunity in this case.
  • Early information indicates that COVID-19 vaccination may reduce the severity of illness, as well as the incidence of illness. As we learn more about the efficacy of the vaccine, we will also learn more about potential long-term protection it may bring.
  • Describe how the vaccine was tested in large clinical trials and what is currently known about its safety and effectiveness.
  • Be transparent that the vaccine is not a perfect fix. Patients will still need to practice other precautions like wearing a mask, social distancing, handwashing and other hygiene measures until public health officials say otherwise.

Two vaccines are needed to provide the best protection against COVID-19.

  • The first vaccine primes the immune system and helps recognize the virus. The second vaccine strengthens the immune response.
  • The two doses are given a few weeks apart (e.g. 21 or 28 days depending on vaccine type). Explain the dosing options available in your office and advise the patient that they can set up an appointment before they leave to come back for a second dose.
  • Provide members with a vaccination record card to ensure that they know when they received their first vaccine, what type of vaccine they received, and when they need to come back and receive their second vaccine.
  • Direct them to their insurance health plan to set up non-emergency transportation, if applicable.

List the most common side effects from vaccination are and how severe they may be (e.g. fever, headache, body aches, cold symptoms). Emphasize that a fever could be a potential side effect and when to seek medical care.

  • Symptoms will typically go away on their own within a week. Let them know when they should seek medical care if their symptoms don’t go away.
  • Explain that the vaccine cannot give someone COVID-19 as the vaccine does not contain a live coronavirus.
  • Explain that side effects are a sign that the immune system is effectively working.

No! The vaccine will be at no cost to patients. They will not have to pay for either dose of the COVID-19 vaccine.

Peach State Health Plan is closely following advancements in the prevention and treatment of COVID-19, including vaccinations. As a healthcare provider, you will play an integral role as COVID-19 vaccines become available. We want to update you on important new information about vaccine coverage.  

To prepare for vaccine administration, the Centers for Medicare and Medicaid (CMS) have begun to publish guidance for Medicaid and Children’s Health Insurance Program (CHIP) providers. Similar to other COVID-19 services, the vaccines will be offered at no cost to your patients. In addition:

  • Peach State Health Plan will configure its systems to properly adjudicate COVID-19 vaccine-related claims in accordance with Georgia’s coverage determinations for Medicaid beneficiaries
  • Member liability will be $0
  • The Pfizer Vaccine is approved for members 16 and older
  • The Moderna Vaccine is approved for members 18 and older
  • Non-participating provider pre-authorization requirements will be waived
  • Members enrolled in Planning for Healthy Babies receiving Family Planning benefits only are excluded. Providers should contact HRSA Provider Relief Fund (Uninsured individuals and Limited Benefit Plans) for reimbursement for vaccines administration.

The American Medical Association (AMA) has published updates tto the Current Procedural Terminology (CPT®) code set that includes new vaccine-specific codes to report immunizations for the novel coronavirus (SARS-CoV-2).

In addition, effective December 17, 2020, DCH will begin reimbursing pharmacy providers through the Pharmacy Point of Sale System for the administration of COVID-19 vaccines for GA Medicaid Fee-for-Service (FFS) members. 

Code

CPT Short Descriptor

Labeler Name

Vaccine/Procedure Name

Reimbursement Admin. Fee

91300

SARSCOV2 VAC

30MCG/0.3ML IM

Pfizer

Pfizer-BioNtech Covid-19 Vaccine

 

0001A

ADM SARSCOV2 VAC

30MCG/0.3ML 1ST

Pfizer

Pfizer-BioNtech Covid-19 Vaccine

Administration – First Dose

$10

0002A

ADM SARSCOV2 VAC

30MCG/0.3ML 2ND

Pfizer

Pfizer-BioNtech Covid-19 Vaccine

Administration – Second Dose

$10

91301

SARSCOV2 VAC

100MCG/0.5ML IM

Moderna

Moderna Covid-19 Vaccine

 

0011A

ADM SARSCOV2 VAC

100MCG/0.5ML 1ST

Moderna

Moderna Covid-19 Vaccine

Administration – First Dose

$10

0012A

ADM SARSCOV2 VAC

100MCG/0.5ML 2ND

Moderna

Moderna Covid-19 Vaccine

Administration – Second Dose

$10

Additionally, CMS has also published a set of toolkits to help providers prepare to swiftly administer the vaccine once it is available. If you have any further questions about this upcoming vaccine or the COVID-19 services Peach State Health Plan covers, please contact Provider Services at 866-874-0633.