Skip to main content

COVID-19 Vaccine Administration Procedure Code 0004A is Now a Benefit for Individuals 16 Years Old or Older

Last updated on 1/11/2022

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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 December 9, 2021, in accordance with the U.S. Food and Drug Administration’s (FDA) amended Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID-19 vaccine, COVID-19 vaccine administration code 0004A (the booster dose of the Pfizer-BioNTech COVID-19 vaccine) is now a benefit of Medicaid, Healthy Texas Women (HTW), the Family Planning Program (FPP), and the Children with Special Health Care Needs (CSHCN) Services Program for clients 16 or 17 years old.

Procedure code 0004A should be administered at least 6 months after completion of the primary series of the Pfizer-BioNTech COVID-19 vaccine.

As a reminder, vaccine procedure code 91300 is informational only while the vaccine is distributed to providers free of charge.

For more information, visit https://dshs.texas.gov/covidvaccine/ or https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html.

The booster dose of the Pfizer-BioNTech (procedure code 0004A) is a benefit of Medicaid, Healthy Texas Women (HTW), and the Family Planning Program (FPP) for the following places of service and provider types:

Place of Service

Provider Type

Office

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

Home

PA, NP, CNS, Physician, Clinic/Group Practice, Home Health Agency, CCP Provider

Outpatient Hospitals

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

Other Locations

PA, NP, CNS, Physician, Clinic/Group Practice, FQHCs, CCP Provider, RHCs

The booster dose of the Pfizer-BioNTech (procedure code 0004A) is a benefit of the Children with Special Health Care Needs (CSHCN) Services Program for the following places of service and provider types:

Place of Service

Provider Type

Office

PA, Advanced Practice Registered Nurse (APRN), Physician, Clinic/Group Practice, Pharmacist, Federally Qualified Healthcare Centers (FQHC), CCP Provider, Nephrology (Hemodialysis, Renal Dialysis), Rural Health Clinics (RHC)

Home

PA, APRN Physician, Clinic/Group Practice, Home Health Agency, CCP Provider

Outpatient Hospitals

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

Other Locations

PA, APRN, Physician, Clinic/Group Practice, FQHCs, CCP Provider, RHCs

Procedure code M0201 (COVID-19 vaccine administration inside a patient’s home) can be billed in the home setting with procedure code 0004A for clients 16 or 17 years old as of December 9, 2021.

Affected claims with dates of service on or after December 9, 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.