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Provider Notices
COVID-19 Vaccine and Administration Billing
1/12/2021 7:51:25 AMFor 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 |
|
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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