Coding Guidance for Pharmacies

Updated: Feb. 10, 2022; revised March 4, 2022

Open each tab below to see the New York State Department of Health’s policies, as well as guidance from our pharmacy vendor Express Scripts, that EmblemHealth has adopted for our own Medicaid members:

New York State (NYS) Medicaid Policy for Coverage:

  • The NYS Medicaid program will reimburse NYS Medicaid-enrolled pharmacies for the administration and dispensing of COVID-19 therapeutics.
  • A pharmacy will only be reimbursed for a dispensing fee if a COVID-19 therapeutic is dispensed, but not administered.
  • A pharmacy will be reimbursed a dispensing fee and an administration fee if a COVID-19 therapeutic is dispensed and administered.
  • The COVID-19 therapeutic must be approved or granted Emergency Use Authorization (EUA) through the FDA, and must be ordered and administered in accordance with the FDA approval or authorization.
  • Evusheld (tixagevimab and cilgavimab) must be prescribed for an individual patient by a physician, nurse practitioner, or physician assistant licensed or authorized under New York State law to prescribe monoclonal antibodies for prevention of COVID-19.
  • Pharmacists must adhere to guidance in the PREP Act. For further information, see the following: Fact Sheet Expanding Access to Therapeutics COVID-19 HHS PREP ACT Declaration: 9th Amendment.
  • Preauthorization is not required.
  • Providers are prohibited from charging Medicaid members a copayment or any cost-sharing responsibility for COVID-19 therapeutics, consistent with other COVID-19 Medicaid guidance.

 

Administration Codes and Effective Dates for COVID-19 Therapeutics

Code Labeler Name Procedure Name Effective Date
Q0247 GSK Injection, sotrovimab, 500 mg 5/26/2021
M0247 GSK Intravenous infusion, sotrovimab, includes infusion and post administration monitoring 5/26/2021
Q0220 AstraZeneca Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, 300 mg 12/8/2021
M0220 AstraZeneca Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, includes injection and post administration monitoring 12/8/2021
J0248 Gilead Injection, remdesivir, 1 mg 1/21/2022 FDA-approved for outpatient use
96365 N/A Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less N/A
Q0222 Eli Lilly injection, bebtelovimab, 175 mg 2/11/2022
M0222 Eli Lilly Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less 2/11/2022

The above infusion codes are reimbursable when provided in a hospital outpatient department or physician´s office. Providers should bill the codes outlined in this guidance via the ordered ambulatory and/or physician fee schedule. Note: Providers should bill CPT code "96365" to be reimbursed for the infusion/injection when administering J2048 (remdesivir).

Coronavirus (COVID-19) Update: FDA Limits Use of Certain Monoclonal Antibodies to Treat COVID-19 Due to the Omicron Variant.

Claims will only be reimbursed for injections or infusions provided on dates of service within the effective dates noted in the table above.

Effective Dec. 1, 2021, New York State (NYS) Medicaid provides reimbursement for Coronavirus Disease 2019 (COVID-19) vaccination counseling to unvaccinated Medicaid members/enrollees to encourage the administration of the COVID-19 vaccine.

The provider types listed below may bill for COVID-19 vaccine counseling:

  • Physicians
  • Nurse practitioners (NPs)
  • Licensed midwives
  • Pharmacists
  • Article 28 clinics billing ordered ambulatory
  • Federally Qualified Health Centers (FQHCs)
  • Other qualified rate-based providers

Reimbursement for COVID-19 vaccination counseling is limited to unvaccinated individuals who have not received an initial/first dose of the COVID-19 vaccine and do not have an appointment to receive an initial/first dose of the COVID-19 vaccine, but who are eligible to receive the COVID-19 vaccination. If providing counseling to parents, guardians, or caregivers regarding vaccination of children, providers must bill NYS Medicaid under the Medicaid Client Identification Number (CIN) of the enrolled children. The counseling must be delivered in the presence of the children and their parents, guardians, or caregivers.

The COVID-19 vaccine counseling session must be documented in the medical or pharmacy record and must include the following:

  • Confirming with the patient, or the parent, guardian, or caregiver (if appropriate) that the patient is unvaccinated (the patient has not received an initial/first dose of a COVID-19 vaccine);
  • Confirming that the patient does not already have an appointment scheduled to receive an initial/first dose;
  • Confirming patient consent of the parent, guardian, or caregiver (if appropriate) to receive the counseling;
  • Confirming vaccination status in the New York State Immunization Information System (NYSIIS), whenever possible*;
  • Strongly recommending the COVID-19 vaccination (unless medically contraindicated, in which case the counseling session is not billable);
  • Counseling the patient, along with their parent, guardian, or caregiver (if appropriate), on the safety and effectiveness of COVID-19 vaccines;
  • Answering any questions that the patient or parent, guardian, or caregiver has regarding COVID-19 vaccination;
  • Counseling the patient, along with their parent, guardian, or caregiver (if appropriate), for a minimum of eight minutes; and
  • Arranging for vaccination or providing information on how the patient can get vaccinated for COVID-19.

* If there is a pharmacy software limitation, a pharmacist can provide an attestation that the above actions have been met: "Meets NYS Department of Health (DOH) Counseling Criteria for COVID Vaccination".

A provider may only request reimbursement once per unvaccinated member. Counseling on second and subsequent doses is not billable.

Physicians, Nurse Practitioners, and Licensed Midwives

A provider submitting a professional claim should bill Current Procedural Terminology (CPT) code "99429"Unlisted Preventative Medicine Service, for reimbursement of COVID-19 vaccination counseling.

A provider may bill CPT code "99429":

  • When COVID-19 vaccine counseling is provided to a member for a minimum of eight minutes and all the other criteria listed above are met and documented; or
  • In addition to an Evaluation and Management (E&M) code for a visit when all the components of both the E&M and COVID-19 counseling requirements are met and documented.

A provider may not bill CPT code "99429":

  • If the patient has already received an initial/first dose of a COVID-19 vaccination; or
  • If the patient already has an appointment scheduled to receive an initial/first dose of a COVID-19 vaccination.

Pharmacists

When providing a minimum of eight minutes of COVID-19 vaccination counseling to a patient, the pharmacist may bill for counseling.

In order to appropriately submit claims for COVID-19 vaccines, in which counseling and administration of the vaccine has occurred, please include the following:

  • A valid and FDA-approved NDC in Field 407-D7 (Product/Service ID)
  • A Submission Clarification Code in Field 420-DK (Submission Clarification Code): 02 (initial dose), 06 (second dose), 07 (additional dose for immunocompromised), or 10 (booster dose)
    • If an SCC code is not included, the following rejection will occur: NCPDP Reject 34 (Missing/Invalid Submission Clarification Code)
  • A professional service code in Field 440-E5 of PE (Patient Education)
    • If this code is not included on the claim, a counseling fee may not be paid.
  • An incentive amount must be submitted in Field 438-E3 (Incentive Amount Submitted).
  • Pharmacies may submit COVID-19 counseling service fees to the medical benefit when the patient did not receive the vaccine, but counseling services were conducted by the pharmacy.

Note: COVID-19 vaccine billing guidance can be found on the NYS DOH "COVID-19 Guidance for Medicaid Providers" web page.

(See also Billing Guidance for the Administration of COVID-19 Vaccines)

Article 28 Clinics Billing Ordered Ambulatory

Article 28 clinics, including hospital outpatient departments (HOPDs) and Diagnostic and Treatment Centers (D&TCs), should bill an ordered ambulatory claim for COVID-19 vaccine counseling using the CPT code "99429".

HCPCS Code Code Description    Fee
99429 Unlisted Preventive Medicine $25.00

Federally Qualified Health Centers

FQHCs should bill their prospective payment system (PPS) rate when providing COVID-19 vaccination counseling, but FQHCs are encouraged to perform other evaluation and management, or clinical services included within the PPS rate in connection with the counseling session.

Other Qualified Rate-Based Providers

The rate-based provider types listed below may bill for COVID-19 vaccination counseling using rate code "5521" with Category of Service (COS) code "0268" when provided to unvaccinated Medicaid members:

  • Skilled Nursing Facilities (SNFs)
  • Certified Home Health Agencies (CHHAs)
  • Hospice
  • Adult Day Health Care (ADHC)
  • Inpatient Hospitals
  • Assisted Living Programs (ALPs)
  • Voluntary Foster Care Agencies (VFCAs)
Rate Code Rate Code Description Fee
5521 COVID-19 VACCINE COUNSEL TO UNVAC INDV - EIGHT MINUTE MINIMUM $25.00

COVID-19 Vaccine Counseling Provided Via Audio-Only (Telephonic) Telehealth

Physicians, NPs, and licensed midwives should bill the CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth. Article 28 clinics (including HOPDs and D&TCs) should bill an ordered ambulatory claim using the CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth. Pharmacists may provide audio-only (telephonic) telehealth counseling and must document the counseling in the pharmacy record with the claim that is submitted for CPT code "99429".

The other rate-based providers listed above should bill using rate code "5521" with CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth. FQHCs should bill the off-site rate code "4012" with CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth.

NYS Medicaid Coverage Policy

A. NYS Medicaid Will Not Reimburse for the Cost of COVID-19 Vaccine

  1. Payment will not be made to NYS Medicaid providers for the cost of COVID-19 vaccine because the vaccine is available at no cost to providers. Providers must not bill the Current Procedural Terminology (CPT) code for the vaccine.
  2. In order to obtain COVID-19 vaccine at no cost, Medicaid-enrolled providers must be legally authorized to administer the vaccine and also enroll as COVID-19 vaccine providers with the Centers for Disease Control and Prevention (CDC), the NYS Department of Health Bureau of Immunization, or the NYC Department of Health and Mental Hygiene (NYCDOHMH) Bureau of Immunization. Such providers are considered qualified providers by the Medicaid program for the purpose of COVID-19 vaccine administration.
  3. For information on how to enroll in the NYS COVID-19 Vaccination Program and how to register for the NYSIIS or Citywide Immunization Registry (CIR), please visit COVID-19 Vaccine Information for Providers.
  4. Note that this program is distinct from the Vaccines for Children (VFC) Program and separate enrollment is required.

B. Claims Submission

In order to appropriately submit claims for COVID-19 vaccines, in which counseling and administration of the vaccine has occurred, please include the following:

  • A valid and FDA-approved NDC in Field 407-D7 (Product/Service ID)
  • A Submission Clarification Code in Field 420-DK (Submission Clarification Code): 02 (initial dose), 06 (second dose), 07 (additional dose for immunocompromised), or 10 (booster dose)
    • If an SCC code is not included, the following rejection will occur: NCPDP Reject 34 (Missing/Invalid Submission Clarification Code).
  • A professional service code in Field 440-E5 of PE (Patient Education)
    • If this code is not included on the claim, a counseling fee may not be paid.
  • An incentive amount must be submitted in Field 438-E3 (Incentive Amount Submitted).
  • Pharmacies may submit COVID-19 counseling service fees to the medical benefit when the patient did not receive the vaccine, but counseling services were conducted by the pharmacy.

COVID-19 vaccine claims administered to patients where counseling services were not conducted will continue to submit claims with:

  • A Submission Clarification Code in Field 420-DK (Submission Clarification Code): 02 (initial dose), 06 (second dose), 07 (additional dose for immunocompromised), or 10 (booster dose)
    • If an SCC code is not included, the following rejection will occur: NCPDP Reject 34 (Missing/Invalid Submission Clarification Code).
  • A professional service code in Field 440-E5 of MA (Medication Administration)
    • The MA code is used to pay the pharmacy only for the administration of the vaccine.
  • An incentive amount must be submitted in Field 438-E3 (Incentive Amount Submitted).
  • Pharmacies may submit COVID-19 counseling service fees to the medical benefit when the patient did not receive the vaccine, but counseling services were conducted by the pharmacy.

C. Reimbursement for Administration of Authorized COVID-19 Vaccines

  1. The NYS Medicaid program, including the Medicaid FFS program and Medicaid Managed Care (MMC), will reimburse NYS Medicaid-enrolled and -qualified providers for the administration of COVID-19 vaccines that have been issued an EUA by the FDA for the prevention of COVID-19.
  2. Reimbursement for administration of COVID-19 vaccines may be based on a patient-specific order or non-patient-specific order ("standing order"). These orders must be kept on file by the provider. Standing orders enable assessment and vaccination of the patient without the need for clinician examination or a patient-specific order from the attending provider at the time of the patient interaction.
  3. The ordering provider´s National Provider Identifier (NPI) is required on the Medicaid claim. Ordering providers, including our EmblemHealth Enhanced Care Prime Network providers, are required to be enrolled in the NYS Medicaid program.
  4. Providers are prohibited from charging Medicaid members a copayment or any cost-sharing responsibility for the COVID-19 vaccine or the administration of the COVID-19 vaccine.
  5. Providers must not bill NYS Medicaid for the administration of the COVID-19 vaccine to members who are also enrolled in Medicare. Dually eligible enrollees will continue to access full coverage of immunization services through Medicare.

Effective Dec. 29, 2021, NYS Medicaid will reimburse pharmacies for dispensing COVID-19 oral antivirals with no member cost-sharing.

Coverage Policy

  • COVID-19 oral antivirals must be approved or granted Emergency Use Authorization (EUA) through the FDA and must be ordered in accordance with the FDA approval or authorization.
  • COVID-19 oral antivirals, Paxlovid and molnupiravir, must be prescribed for an individual patient by a physician, nurse practitioner, or physician assistant licensed or authorized under New York State law to prescribe oral antivirals.
  • Prior authorization is not required.
  • Providers are prohibited from charging Medicaid members a copayment or any cost-sharing responsibility for COVID-19 oral antivirals, consistent with other COVID-19 Medicaid guidance.

Below are the instructions on how to submit COVID antivirals, vaccines, and tests. In order to process claims for these products, please submit claims in accordance with the Express Scripts Provider Manual and the below guidance:

  • Basis of Cost Determination (423-DN) other than a value of “15” (free product at no associated cost).
  • Ingredient Cost Submitted (409-D9) for the free product should be submitted as $0.01.
  • Pharmacies should not submit claims with a Professional Service Code or an Incentive Fee amount.
  • COVID oral antiviral medications are not eligible to receive an administration fee as they are not administered to the patient nor should be prescribed by the pharmacist per FDA Emergency Use Authorization (EUA) guidance.

Medicaid Pharmacy Policy and Billing Guidance for At-Home COVID-19 Testing Coverage
 

Update Effective: Dec. 13, 2021; revised Feb. 10, 2022
 

Effective Dec. 13, 2021, EmblemHealth will cover COVID-19 diagnostic and screening tests with “at-home” sample collection for Medicaid members only with no member cost-sharing. Effective Jan. 10, 2022, a fiscal order is not required for the first eight (8) tests per month. Additional tests may be covered with a fiscal order, when medically necessary. Coverage will be provided for COVID-19 test kits used in accordance with the Centers for Disease Control and Prevention (CDC) recommendations for antigen detection. This aligns with New York State’s coverage policy, which provides for coverage when the:

  • Test is available over-the-counter (OTC) and authorized by the Food and Drug Administration (FDA).
  • Member has symptoms or not.
  • Two (2) OTC tests per claim, with no refills, may be submitted (a test kit may contain two (2) tests and is considered two (2) OTC tests).
  • Up to eight (8) OTC tests per month may be requested by a member at the pharmacy, without a fiscal order.
  • If medically necessary, additional OTC tests will be covered with a fiscal order written by a Medicaid-enrolled practitioner (which includes all the same information contained on a prescription). Refills will not be allowed.
  • Quantities greater than eight (8) tests per month will require verification that the fiscal order was obtained.

 

Pharmacy Billing for COVID- 19 Test Kits

 

Pharmacies may bill using the National Drug Codes (NDCs) provided, which have been derived by using the Universal Product Code (UPC). For a list of tests that are covered, providers can perform a search using the eMedNY formulary search page. Select “Description” in the drop-down field and type in “COVID” to return all tests on the formulary.

 

Table 1
Billing Instructions for COVID-19 Tests

 

NCPDP D.0. Claim Segment Field* Value
436-E1 (Product/Service ID Qualifier) Enter a value of “03” (NDC)
407-D7 (Product/Service ID) Enter one applicable NDC from New York State’s COVID-19 Guidance for Medicaid Providers
444-E9 (Pharmacist ID) Enter Prescriber National Provider Identifier (NPI) number
411-DB (Prescriber ID) Please leave field blank *

* The NCPDP D.0 Companion Guide can be found on eMedNY 5010/D.0 Transaction Instructions .

 

Origin Codes and Serial Codes
 

In the origin code field, use “5” and the corresponding serial number of “99999999” for “Pharmacy dispensing” when applicable for non-patient-specific orders. For quantities greater than eight (8) tests per month that require a fiscal order, the NPI of the Medicaid-enrolled practitioner is required.

Please see the July 2020 Medicaid Update for further guidance on origin code and serial number values that you must submit on the claim.
 

Table 2
OTC COVID-19 Tests – Maximum Reimbursement
 

Reimbursement* Tests per kit
Up to $24 2
Up to $12 1

*Actual reimbursement for each test will be the lower of the maximum reimbursement amount shown in Table 2 above, or the usual and customary U&C price charged to the general public. In accordance with 42 C.F.R. § 447.512(b), pharmacies must provide a U&C price when submitting pharmacy claims for prescription and OTC (nonprescription) items. U&C is defined as the lowest price charged to the general public after all applicable discounts, including promotional discounts and discounted prices associated with loyalty programs.
 

Reminder: The Medicaid program is the payer of last resort and providers should take reasonable measures necessary to ensure that all available options for coverage, including free at-home COVID tests from COVIDtests.gov and third-party insurance, are utilized prior to submitting claims to the Medicaid program.

For further information regarding COVID-19 tests, see: FDA Emergency Use Authorizations for Medical Devices.
 


 

NEW YORK MEDICAID

COVID-19 Sample Collection and Testing Claims Submission

Effective: August 21, 2020

 

In response to the current novel Coronavirus (COVID-19) emergency situation, and pursuant to the New York State Medicaid Fee-for- Service Policy and Billing Guidance for COVID-19 Testing and Specimen Collection at Pharmacies, New York Medicaid plans will reimburse Providers for COVID-19 specimen collection or CLIA waived COVID-19 testing for Medicaid Members, when such collection or testing is in compliance with the Governor’s Executive Order #202.24. 

 

The terms and rates herein are subject to change pursuant to any changes or updated to the New York State Medicaid Fee-for- Service Policy and Billing Guidance for COVID-19 Testing and Specimen Collection.

NCPDP D.0. Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Enter a value of 03.
407-D7 (Product/Service ID) Enter the 11-digit NDC for test kit, if there is no test kit enter valid NDC for specimen collection
440-E5 (Professional Service Code)

Enter a value of MA

411-DB (Prescriber ID)

Enter the Pharmacist National Provider Identifier (NPI) number.

 

Reimbursement for Lab Specimen Collection or CLIA waived COVID-19 Testing*

Description Reimbursement
Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) (NDC 99999-0992-11 only) $23.46
*2019-nCoV Coronavirus, SARS-CoV-2/2019-nCov (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC

$51.31

*Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique $51.31

*Pharmacies performing and billing for COVID-19 testing should not bill for specimen collection. Reimbursement for the test includes specimen collection and generating the lab report. Furthermore, pharmacies who are already being provided payment, from another source, for either lab specimen collection or for COVID-19 testing should not bill Medicaid in addition.

 

Only test kits with an FDA approved Emergency Use Authorization (EUA) are covered.  Specimen collection without a test kit is also covered.  To identify FDA approved tests,see the Test Kit Manufacturers and Commercial Laboratories Table https://www.fda.gov/medical-devices/emergency-situations-medical-devices/emergency-use-authorizations#covid19ivd

 

Subject to change, the following are sample NDCs covered under this program:

NDC 11877-0011-26       ID NOW COVID-19 TEST KIT

NDC 22066-0005-11       RAPID RESPONSE COVID-19 TEST

NDC 60004-0417-80       COVID-19 Test Administration

NDC 99999-0992-11       SPECIMEN COLLECTION

NDC 00042-0222-24       COVID-19 TEST SPECIMEN COLLECT

NDC 14613-0339-08       SOFIA SARS ANTIGEN FIA TEST

 

Please be aware that the Medicaid program prohibits providers from billing members for charges for COVID-19 protective measures including personal protective equipment (PPE). Please ensure that only the copay returned in the NCPDP response field is collected from a Medicaid member, and no additional charges are added for PPE. 

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