New COVID-19 vaccines spur CPT coding overhaul

The American Medical Association (AMA) CPT Editorial Panel has updated its COVID-19 vaccine coding guidance with the release of COVID shots reformulated to target new variants. The updated guidance follows recommendations from the Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) that everyone six months and older receive the new vaccines. There are new CPT codes for Pfizer and Moderna’s vaccines, as well as a new administration code that applies to all COVID vaccines.

Effective Nov. 1, all previously approved COVID-19 vaccine product and administration codes and Appendix Q will be deleted from the CPT code set, with the exception of the Novavax vaccine product code (CPT code 91304). That will remain active in anticipation of the approval of that company’s updated vaccine, which is under FDA review.

The FDA approved the updated Pfizer and Moderna vaccines on Sept. 11, 2023, and the CDC endorsed the Advisory Committee on Immunization Practices’ recommendations the following day. The new CPT codes are now active (the updated vaccines should be available soon):

Payment rates 

Medicare will be required to pay 95% of the average wholesale price (AWP), and the CDC expects the Pfizer vaccine to cost about $115 per dose and the Moderna vaccine to cost about $128 per dose. Medicare will continue to provide additional payment when the vaccine is administered in the patient’s home. Medicare fully covers both the vaccine and administration at no cost to patients. For more information, review the Medicare COVID-19 Vaccine Shot Payment webpage and the Centers for Medicare & Medicaid Services' vaccine pricing page. 

Private payer rates will vary depending on contract terms. Contact your provider relations representatives to learn more. The vaccine and its administration will also be covered without cost sharing for most patients with private coverage, but there are some exceptions (e.g., grandfathered plans), and it is best to verify a patient’s coverage in advance.

The CDC’s Bridge Access Program can defray the cost of the COVID-19 vaccine for adults who are uninsured or whose insurance does not cover all costs. The program is currently scheduled to run through Dec. 31, 2024. Children 18 years and younger who are Medicaid-eligible, uninsured, underinsured, or American Indian or Alaska Native may receive the COVID-19 vaccine through the Vaccines for Children Program.

Additional coding information is available in the CPT® Assistant Special Edition: August Update and on the AMA’s COVID-19 CPT vaccine and immunization codes webpage.

— Erin Solis, AAFP Manager of Practice & Payment 

Posted on Sept. 15, 2023