Just one day after the Federal Drug Administration (FDA) approval for the emergency use of a new COVID-19 antibody drug, there are already new billing and payment policies in place to make sure providers have access to this new treatment.  The new drug, bamlamivimab will be used to treat mild-to-moderate COVID in a certain adult and pediatric population.

Centers for Medicare and Medicaid (CMS) said it plans to pay 95% of the average wholesale price of the treatment to providers.  However, at first it is expected to be free of charge.  Although the drug is free, CMS will be reimbursing providers for the administration of the drug.  For one hour of infusion and post-administration in a hospital outpatient setting, the provider can look for a reimbursement of $309.60. This billing can be done on a roster billing or on a single claim manner.

Providers will have to submit documentation showing that the patient is being treated for mild-to-moderate COVID-19 and are at high risk of the disease progressing to a severe status, possibly including hospitalization.  On roster billing the provider who made the decision to administer the dose will need to be included.  The following codes should only be billed if the provider receives the drug for free:

• Q0239 – Injection, bamlanivimab-xxxx, 700 mg
• M0239 – Intravenous infusion, bamlanivamab-xxxx, includes infusion and post administration monitoring

CMS intends that there be a broad access to the drug, therefore, it will be free to Medicare beneficiaries.  This means no payment on the part of the patient.  It is expected that hospital-based infusion centers, home health agencies, and nursing homes be able to administer this drug under the new policy. 

First-line workers will probably receive the vaccine first, healthcare workers being on that list.

Due to Phase 3 clinical trial results, Pfizer and BioNTech have released the mRNA- based COVID-19 vaccine.  This is the first of many projected vaccine releases to come.  About 50 million vaccine doses are expected by the end of 2020 with 1.3 billion doses available by 2021.  It is thought that by the third week in November, the authorization to use the drug in an emergent situation will be issued. 

Unique CPT codes have been set up to be effective with this release of the COVID-19 vaccine:

• 91300 – Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use
• 91301 – Severe acute respiratory syndrome coronavirus 2 (sARS-C0V-2) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL, for intramuscular use

There are also unique administration codes for these Category I CPT codes.  They were developed to enable more granular reporting and tracking of the vaccine, even if the vaccine is administered for free:

• 0001A – Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose
• 0002A – Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose
• 0011A – Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) vaccine, mRNA-LNP, spike protein, preservative free, 100/0.5mL dosage, first dose
• 0012A – Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) vaccine, mRNA-LNP, spike protein, preservative free, 100/0.5mL dosage, second dose

There will be continuous updates to the coding of the drugs being developed for the COVID-19 pandemic.  It will be the provider’s responsibility to keep up to date on these changes.  The best information available is on CMS’ website directly.

References

Centers for Medicare and Medicaid Services. (2020). CMS Takes Steps to Ensure Medicare Beneficiaries Have Wide Access to COVID-19 Antibody Treatment [News Brief]. CMS. https://www.cms.gov/newsroom/press-releases/cms-takes-steps-ensure-medicare-beneficiaries-have-wide-access-covid-19-antibody-treatment

LaPointe, J. (2020). AMA Updates CPT Code Set to Include COVID-19 Vaccine Codes. RevCycle Intelligence. Retrieved November 13, 2020, from https://revcycleintelligence.com/news/ama-updates-cpt-code-set-to-include-covid-19-vaccine-codes

LaPointe, J. (2020, November 11). CMS Details Medicare Payment for New COVID-19 Antibody Drug. RevCycle Intelligence. Retrieved November 13, 2020, from https://revcycleintelligence.com/news/cms-details-medicare-payment-for-new-covid-19-antibody-drug?eid=CXTEL000000602992&elqCampaignId=16808&utm_source=nl&utm_medium=email&utm_campaign=newsletter&elqTrackId=ed039189b0f54a55b73e2a677a5b5212&elq=d60cfb0dd24641d18ba3dfb4386dedf1&elqaid=17592&elqat=1&elqCampaignId=16808