COVID-19 booster shots: who’s eligible, and how to code them
Editor's note: the codes in this article are only active until Nov. 1, 2023. For updated codes, see this post.
The Centers for Disease Control and Prevention (CDC) is recommending a booster shot of the Pfizer-BioNTech COVID-19 vaccine for certain patients. The agency recommends a booster for individuals 65 and older and long-term care residents, as well as adults younger than 65 who are at high risk for severe COVID-19 due to underlying medical conditions or at high risk for COVID-19 exposure due to their institutional or occupational settings.
The booster should be administered at least six months after a person’s primary series of the Pfizer-BioNTech COVID-19 vaccine. The agency will review booster shot data for the Moderna and Johnson & Johnson vaccines once it’s available.
At this time, the CDC is NOT recommending COVID-19 booster shots for the general public. Its specific recommendations are:
The following populations should receive the Pfizer COVID-19 booster shot:
- People 65 years and older and residents of long-term care settings and
- People aged 50-64 years with underlying medical conditions.
The following populations may receive the booster shot:
- People aged 18-49 with underlying medical conditions, based on their individual benefits and risks, and
- People aged 18-64 who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting, based on their individual benefits and risk.
The American Medical Association (AMA) has updated its coding guidance to include a CPT administration code for the Pfizer booster. (The AMA’s COVID-19 vaccine coding tool is available here, and the FPM Getting Paid COVID-19 vaccines coding guide is available here.)
| Pfizer-BioNTech vaccine CPT code | Administration codes |
|---|---|
| 91300 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted, for intramuscular use | • 0001A (1st dose) • 0002A (2nd dose) • 0003A (3rd dose) • 0004A (booster) |
Note that the CPT administration code for the booster is different than for the third dose. As a reminder, the third dose is recommended for individuals with moderately to severely compromised immune systems that may not have built the same level of immunity with a two-dose series compared to those who are not immunocompromised.
Medicare and most commercial payers will cover the COVID-19 vaccine and administration, including boosters, without any cost-sharing for eligible individuals.
— Erin Solis, Manager, Practice & Payment at the American Academy of Family Physicians
Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use.