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Provider Notices

COVID-19 Vaccine and Administration Billing

1/12/2021 7:51:25 AM

For Medicaid these codes may be billed for ‘reporting only’ and would need to be billed with $0.01. For Commercial these codes may also be billed as "reporting only", with $0.00, $0.01 or $0.02.  PacificSource will reimburse solely for the administration of the vaccine. For Medicare, the vaccine and administration codes must be billed to Traditional Medicare for reimbursement. Please refer to the chart below for the appropriate administration code of the vaccine provided.

Vaccine Code

Vaccine Code Descriptor

Vaccine Administration Code(s)

Vaccine Manufacturer

Vaccine Name(s)

NDC 10/NDC 11 Labeler Product ID (Vial)

Dosing Interval

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)

Pfizer, Inc

Pfizer-BioNTech COVID-19 Vaccine

59267-1000-1

59267-1000-01

21 days

91301

 

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage, diluent reconstituted, for intramuscular use

0011A (1st dose)

0012A (2nd dose)

Moderna, Inc

Moderna COVID-19 Vaccine

80777-273-10

80777-0273-10

28 days

91302

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenivirus Oxford 1 (ChAdOx1) vector, preservative free, 5x10 viral particles/0.5mL dosage, for intramuscular use

0021A (1st dose)

0022A (2nd dose)

AstraZeneca, Plc

AstraZeneca COVID-19 Vaccine

0310-1222-10

00310-1222-10

28 days

 


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