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COVID-19 Vaccine Administration Procedure Code 0004A Now a Benefit for Individuals 12 or Older

Last updated on 1/25/2022

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 January 3, 2022, 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 12 years old or older.

The booster dose of the Pfizer-BioNTech COVID-19 vaccine should be administered at least five months after completion of the primary series of the Pfizer-BioNTech COVID-19 vaccine.

In addition, on January 7, 2022, the FDA updated the EUA for the booster dose of the Moderna COVID-19 vaccine (procedure code 0064A) to be administered at least five months after completion of the primary series for clients 18 years old or older.

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.

Administration of the booster dose of the Pfizer-BioNTech COVID-19 vaccine (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 (FQHCs), Comprehensive Care Program (CCP) Provider, Nephrology (Hemodialysis, Renal Dialysis), Rural Health Clinics (RHCs), 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

Administration of the booster dose of the Pfizer-BioNTech COVID-19 vaccine (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 (FQHCs), CCP Provider, Nephrology (Hemodialysis, Renal Dialysis), Rural Health Clinics (RHCs)

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 individuals 12 or older as of January 3, 2022.

Affected claims with dates of service on or after January 3, 2022, 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.