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Important Updates About Increased Payments for COVID-19 Vaccinations for Homebound Patients

Important Updates About Increased Payments for COVID-19 Vaccinations for Homebound Patients

Important Updates About Increased Payments for COVID-19 Vaccinations for Homebound Patients

Courtesy of the National Association for Home Care & Hospice

The Centers for Medicare & Medicaid Services (CMS) hosted a Special Open Door Forum on Thursday, June 10, 2021, about the increased payment amounts for providers that vaccinate homebound Medicare beneficiaries for the Coronavirus disease 2019 (COVID-19).

Effective June 8, Medicare will pay providers an additional $35 per dose for administering the COVID-19 vaccine in the home for certain beneficiaries who have difficulties leaving their homes or are hard to reach. Medicare will pay the $35 in addition to the standard administration amount of $40 per dose for a total payment of $75 for a single-dose vaccine or $150 for both doses of a two-dose vaccine. The rates will be geographically adjusted based on where the vaccine is administered.

The additional payment amount applies if a beneficiary:

  • Has a condition that makes them more susceptible to contracting a pandemic disease such as COVID-19.
  • Is generally unable to leave the home, and if they do leave home, it requires a considerable and taxing effort.
  • Has a disability or faces clinical, socioeconomic, or geographical barriers to getting a COVID-19 vaccine in settings other than their home.
  • Faces challenges that significantly reduce their ability to get vaccinated outside the home, such as with transportation, communication, or caregiving.

There is no requirement that the practitioner certifies the patient is homebound or otherwise unable to receive the vaccine outside of the home. However, the provider should document in the applicable medical record why the beneficiary had to be vaccinated in the home.

The beneficiary must be located in either:

  • A private residence
  • Temporary lodging (for example, a hotel or motel, campground, hostel, or homeless shelter)
  • An apartment in an apartment complex or a unit in an assisted living facility or group home
  • A beneficiary’s home that’s made provider-based to a hospital during the COVID-19 public health emergency

Additional payments are not available when the vaccine is provided:

  • In a communal space of a multi-unit living arrangement
  • Inpatient Hospital, Medicare skilled nursing facility, or Medicaid nursing facility
  • Outpatient hospital, physician office, or clinic
  • Patient-assisted living facility participating in the Centers for Disease Control and Prevention (CDC) Pharmacy Partnership for Long-Term Care Program when their residents are vaccinated through this program

Medicare only pays the additional amount for administering the COVID-19 vaccine in the home if the sole purpose of the visit is to administer a vaccine. Medicare doesn’t pay the additional amount if another Medicare service is provided in the same home on the same date. In those situations, Medicare pays $40 per dose for administering the vaccine. If the provider administers the COVID-19 vaccine to more than one beneficiary in a single home on the same day, Medicare pays the additional payment amount of $35 only once per date of service in that home. For example, if the provider administers a single-dose vaccine on the same date to two beneficiaries in the same home, Medicare pays approximately $115 ($35 for the in-home vaccine administration rate plus 2 × $40 for each dose of the COVID-19 vaccine).

In addition to the usual billing codes used on vaccine claims the provider will need to include Healthcare Common Procedure Coding System (HCPCS) code M0201 to indicate that the vaccine was administered in the home and the provider is eligible to receive the additional payment.

If roster billing for administering the COVID-19 vaccine in the home, the provider must submit two roster bills:

  • A roster bill containing the appropriate Current Procedural Terminology (CPT) code for the product and dose-specific COVID-19 vaccine administration
  • A second roster bill containing the HCPCS Level II code (M0201) for the additional in-home payment amount

Providers may submit a single set of roster bills (one containing M0201 and another containing the appropriate CPT code) for multiple beneficiaries who get the COVID-19 vaccine in their individual units of a multi-unit living arrangement.

Home Health and Hospice Billing for COVID 19 Vaccines

Type of Bill

The types of bills to report for the COVID-19 vaccine on the home health and hospice claim form, or electronic equivalent, are:

  • 341 – Home Health Outpatient (Part B)
  • 81X – Hospice (non-hospital-based)
  • 82X – Hospice (hospital-based)

COVID-19 Vaccines and Administration

Revenue Codes

  • 0771 — Preventive care services, vaccine administration; per CMS, although there are more accurate revenue codes available for reporting of the infusions, the current guidance is for providers to utilize revenue code 0771 to report the infusion until further instructions are issued
  • 0636 — Pharmacy, drugs requiring detailed coding

Current Procedural Terminology

COVID-19 vaccines and administration codes are under Payment Allowances and Effective Dates for COVID-19 Vaccines and their Administration During the Public Health Emergency.

For homebound beneficiaries, providers must include HCPCS code M0201

Condition Codes

  • A6 – 100 percent payment
  • 78 – New coverage not implemented by Medicare Advantage (billed on claims for Medicare Advantage beneficiaries only); if the patient is enrolled in a Medicare Advantage plan, submit the COVID-19 vaccine claims to original Medicare in 2020 and 2021

Diagnosis Codes

  • Z23 – Encounter for immunization; per CMS, this code must be included when reporting an encounter for the COVID-19 vaccine or monoclonal antibody treatment
  • U071 — COVID-19
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