COVID-19 Monoclonal Antibody Billing Update

February 8, 2022  by  Allzone MS   173

covid-19-monoclonal-antibody-billing-update

Ever since a public health emergency (PHE) for COVID-19 was declared on Jan. 27, 2020, there has been several new HCPCS Level II codes created for monoclonal antibody (mAb) products and administration. As confusing as all these new codes and billing requirements have been, nothing has caused as much trouble as the latest change for billing COVID-19 vaccines and mAb infusions for Medicare Advantage (MA) patients.

Apparently, many did not get the memo that, effective Jan. 1, 2022, Original Medicare will no longer pay for COVID-19 vaccines and mAbs provided to MA patients (except MA hospice patients, but excluding MA plans that participate in the Hospice Benefit Component of the Value-Based Insurance Design Model). Providers should now bill the patient’s MA plan directly.

Medicare Administrative Contractor (MAC) Novitas Solutions advises providers to include condition code (CC) 78 New coverage not implemented by Medicare Advantage on Medicare Part A UB04 institutional claims for COVID-19 vaccines and/or infusion products. For COVID-19 vaccines, only, also include CC A6 100 percent payment on the claim form.

“If your claim was rejected for missing CC 78, please correct, and resubmit your claim,” the MAC for jurisdictions H and L states in a billing alert.

mAb Product and Administration Codes

Here are the most current codes for investigational monoclonal antibody therapies with emergency use authorization (EUA) and applicable administration codes:

Q0220 Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 300 mg

M0220 Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), includes injection and post administration monitoring

Payment rate: $150.50

M0221 Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), includes injection and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency

Place of service: Home or residence

Payment rate: $250.50

Effective date: Dec. 8, 2021

Q0240 Injection, casirivimab and imdevimab, 600 mg

Note: Patients meeting criteria may receive an initial dose of 1,200 mg, followed by subsequent dosing of 600 mg every four weeks during exposure. For administration of the subsequent doses, use M0240 or M0241. For the initial dose, use M0243 or M0244.

M0240 Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses

Payment rate: $450

M0241 Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence, this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency, subsequent repeat doses

Payment rate: $750

Place of Service: Healthcare setting or home

Effective date: July 30, 2021

Q0243 Injection, casirivimab and imdevimab, 2400 mg

Q0244 Injection, casirivimab and imdevimab, 1200 mg

M0243 Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring

Effective date: Nov. 21, 2020

M0244 Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency

Place of service: Healthcare setting or home

Effective date: May 6, 2021

Q0245 Injection, bamlanivimab and etesevimab, 2100 mg

M0245 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring

Place of service: Healthcare setting

Effective date: Feb. 9, 2021

M0246 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency

Place of service: Home or residence

Effective date: May 6, 2021

Q0247 Injection, sotrovimab, 500 mg

Payment rate: $2,394

If you got the product for free, do not include the product code on the claim unless …

M0247 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring

M0248 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency

Effective date: May 26, 2021

Q0249 Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg

Payment rate: $6.572

M0249 Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose

M0250 Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose

Payment rate: $450

Type of bill: 12x

Effective date: June, 24 2021

Billing Monoclonal Antibody Therapeutics

Medicare will pay for COVID-19 mAb under the Medicare Part B vaccine benefit through the end of the calendar year that the PHE ends — so at least Dec. 31, 2022. Medicare payment is typically at reasonable cost or at 95 percent of the average sales price (ASP). See payment allowance limits for Medicare Part B drugs, effective Jan. 1, 2022, through March 31, 2022. The above Medicare payment rates for administering COVID-19 monoclonal antibody products are effective for services furnished on or after May 6, 2021, and apply to all providers and suppliers not paid at reasonable cost for these products. Note: Federally qualified health centers and rural health centers have separate billing guidance because they are reimbursed at reasonable cost.

Remember: Medicare doesn’t pay for COVID-19 mAb products that providers receive for free. Only tocilizumab is reimbursable based on number of units administered, so be sure to include units on these claims. “For example,” CMS provides, “if you administer 200mg of tocilizumab in 1 infusion, you should add 200 as the number of units on the claim. If you give 2 infusions in the same day, you should include the total units for both infusions with the product code Q0249 on 1 line (per day).”

If you got the product for free, do not include the product code on the claim unless your system requires a product code to bill for the admin, in which case, enter $0.01 for the billed amount.

Applicable revenue codes for mAb and their administration include 0771 Preventive care services, vaccine administration and 0636 Pharmacy, drugs requiring detailed coding. Use the appropriate diagnosis code such as U071.

Even if you figure out the coding and billing for mAb treatments, documentation will be key in getting these claims paid. Not only must medical necessity of the service be demonstrated in the medical record, signed by the ordering provider, but the clinician must also show that the terms of the product’s EUA were met. EUA fact sheets for the various mAb products are available on the CMS website. These EUAs are revised periodically, so it would be wise to check for updates monthly for the remainder of the PHE for COVID-19.

For More Information: https://www.aapc.com/blog/83965-covid-19-monoclonal-antibody-billing-update/