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COVID-19 Vaccine Administration Procedure Code 0004A is Now a Benefit

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after September 22, 2021, in accordance with the U.S. Food and Drug Administration (FDA) amendment to the Emergency Use Authorization (EUA), COVID-19 vaccine administration code 0004A is now a benefit of Medicaid, Healthy Texas Women (HTW), Family Planning Program (FPP), and the Children with Special Health Care Needs (CSHCN) Services Program.

Procedure code 0004A, the booster dose of the Pfizer-BioNTech COVID-19 vaccine, should be administered at least six months after completion of the primary series of the Pfizer-BioNTech COVID-19 vaccine.

The FDA amendment to the EUA allows for the use of a single booster dose of the Pfizer-BioNTech COVID-19 vaccine, at least six months after completion of the primary series in:

  • Individuals 65 years of age and older
  • Long-term care facility residents
  • Individuals 18 through 64 years of age with underlying medical conditions
  • Individuals 18 through 64 years of age at increased risk for exposure and transmission due to occupational or institutional setting

For more information, visit https://dshs.texas.gov/covidvaccine/ or https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html.

Procedure code 0004A is a Medicaid, HTW, and FPP benefit for the following providers and places of service:

Place of Service

Provider Type

Office

Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Physician, Pharmacist, Certified Nurse Midwife (CNM), Federally Qualified Healthcare Centers (FQHC), Nephrology (Hemodialysis, Renal Dialysis), Rural Health Clinics (RHC), Pharmacy

Home

PA, NP, CNS, Physician, Home Health Agency, CCP Provider

Outpatient Hospitals

FQHCs, Hospitals, Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility, RHCs

Other Locations

PA, NP, CNS, Physician, FQHCs, CCP Provider, RHCs

Procedure code 0004A is a CSHCN Services Program benefit for the following providers and places of service:

Place of Service

Provider Type

Office

PA, Advanced Practice Registered Nurse (APRN), Physician, Pharmacist, CCP Provider, Nephrology (Hemodialysis, Renal Dialysis), Pharmacy

Home

PA, APRN, Physician, CCP Provider

Outpatient Hospitals

Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility, Hospital Providers

Other Locations

PA, APRN, Physician, CCP Provider

Procedure code M0201 (COVID-19 vaccine administration inside a patient’s home) can be billed in the Home setting with procedure code 0004A, as of September 22, 2021.

Affected claims with dates of service on or after September 22, 2021, will be reprocessed, and providers may receive additional payment. Additional payments will be reflected on future Remittance and Status (R&S) Reports. Providers are not required to appeal the claims unless they are denied for additional reasons after the claims reprocessing is complete.

Providers interested in enrolling as a COVID-19 vaccinator should visit https://www.dshs.texas.gov/coronavirus/immunize/provider-information.aspx.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.