Date: July 2, 2021
To: Enrolled Physicians, Advanced Practice Nurses, Physician Assistants, Local Health Departments, Federally Qualified Health Centers, Rural Health Clinics, and Encounter Rate Clinics
Re: Update to COVID-19 Vaccine Administration Coding and Reimbursement Effective June 8, 2021 - Add-on for In-Home Vaccinations of Certain Medicaid Customers
This notice informs providers of an update to coding and reimbursement for COVID-19 vaccination administration provided in the home specifically for patients who have difficulty leaving their homes or are hard-to-reach. This billing guidance applies to claims for participants covered under both traditional Medicaid fee-for-service and the HealthChoice Illinois Medicaid managed care plans and is consistent with Medicare Payment for COVID-19 Vaccination Administration in the Home.
Effective with dates of service beginning June 8, 2021, HCPCS code M0201 has been added to the COVID-19 fee schedule as a covered service and may be billed in addition to the applicable COVID-19 administration code for the vaccine product administered. For a two-dose vaccine, M0201 may be billed for each dose administered in the home setting. Providers may bill M0201 only for the patient meeting the applicable conditions below, even if other Medicaid customers in the household also receive in-home vaccination.
According to the federal Centers for Medicare and Medicaid Services (CMS), there are specific patient situations and locations for which the additional payment applies, in addition to billing and payment restrictions.
Applicable Locations for Add-on:
• Private residence
• Temporary lodging, such as motel/hotel, campground, hostel, homeless shelter
• Apartment within an apartment complex
• Unit within an assisted living facility or group home (not for vaccinations administered in a nursing facility or Medicaid supportive living program (SLP))
Applicable Patient Situations for Add-on:
• The patient has a condition that makes them more susceptible to contracting a pandemic disease such as COVID-19
• The patient is generally unable to leave the home, and if they do leave home it requires a considerable and taxing effort
• The patient has a disability or faces clinical, socioeconomic, or geographical barriers to getting a COVID-19 vaccine in settings other than their home
• The patient faces challenges that significantly reduce their ability to get vaccinated outside the home, such as challenges with transportation, communication, or caregiving
Billing and Payment Restrictions for Add-on:
• The additional amount for administering a COVID-19 vaccine in the home is payable only if the sole purpose of the visit is to administer a COVID-19 vaccine. HCPCS M0201 is not billable if another covered service is provided in the same home on the same date.
• HCPCS M0201 is payable only once per date of service, per home. Although all members of the household may be administered the COVID-19 vaccine on the same date, M0201 is billable only once per date of service, provided at least one Medicaid customer meets the applicable patient situations listed above. For example, if a single-dose vaccine is administered to two (2) Medicaid patients on the same date in the same home, reimbursement will be $121.33 ($37.05 for the in-home vaccine administration rate plus 2 x $42.14 for each dose of the COVID-19 vaccine).
It is the responsibility of the provider to maintain supporting documentation of the above conditions. Providers are attesting to having met those conditions by billing the Department for the M0201 code. Failure to adhere to the above conditions while continuing to bill M0201 shall be considered inappropriate billing subject to recoupment upon post-payment review.
As a reminder, Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), and Encounter Rate Clinics (ERCs) are required to bill, and are reimbursed, for COVID-19 vaccine administration fee-for-service outside the normal encounter rate methodology. This same billing and payment policy is applicable to HCPCS code M0201.
Information on how to register to become a COVID-19 vaccine provider can be found at coronavirus.illinois.gov/vaccines.
Questions regarding this notice may be directed to a billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.
Kelly Cunningham, Administrator
Division of Medical Programs