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Attention providers
What changed?
Retroactive to dates of service on and after April 18, 2023, the Health Care Authority (HCA) added the following COVID vaccine procedure codes to the Apple Health (Medicaid) COVID-19 vaccine clinical policy and fee schedule:
CPT® code Short description Labeler
0121A ADM SARSCV2 BVL 30MCG/.3ML 1 Pfizer
0141A ADM SRSCV2 BVL 25MCG/.25ML 1 Moderna
0142A ADM SRSCV2 BVL 25MCG/.25ML 2 Moderna
0151A ADM SARSCV2 BVL 10MCG/.2ML 1 Pfizer
0171A ADM SARSCV2 BVL 3MCG/0.2ML 1 Pfizer
0172A ADM SARSCV2 BVL 3MCG/0.2ML 2 Pfizer
Retroactive to dates of service on and after April 18, 2023, the HCA deleted the following COVID vaccine procedure codes from the Apple Health (Medicaid) COVID-19 vaccine clinical policy and fee schedule:
CPT® code Short description Labeler
0001A ADM SARSCOV2 30MCG/0.3ML 1ST Pfizer
0002A ADM SARSCOV2 30MCG/0.3ML 2ND Pfizer
0003A ADM SARSCOV2 30MCG/0.3ML 3RD Pfizer
0004A ADM SARSCOV2 30MCG/0.3ML BST Pfizer
0011A ADM SARSCOV2 100MCG/0.5ML 1ST Moderna
0012A ADM SARSCOV 100MCG/0.5ML 2ND Moderna
0013A ADM SARSCOV2 100MCG/0.5ML 3RD Moderna
0051A ADM SARSCV2 30MCG TRS-SUCR 1 Pfizer
0052A ADM SARSCV2 30MCG TRS-SUCR 2 Pfizer
0053A ADM SARSCV2 30MCG TRS-SUCR 3 Pfizer
0054A ADM SARSCV2 30MCG TRS-SUCR B Pfizer
0064A ADM SARSCOV2 50MCG/0.25MLBST Moderna
0071A ADM SARSCV2 10MCG TRS-SUCR 1 Pfizer
0072A ADM SARSCV2 10MCG TRS-SUCR 2 Pfizer
0073A ADM SARSCV2 10MCG TRS-SUCR 3 Pfizer
0074A ADM SARSCV2 10MCG TRS-SUCR B Pfizer
0081A ADM SARSCOV2 3MCG TRS-SUCR 1 Pfizer
0082A ADM SARSCOV2 3MCG TRS-SUCR 2 Pfizer
0083A ADM SARSCOV2 3MCG TRS-SUCR3 Pfizer
0091A ADM SARSCOV2 50 MCG/.5 ML1ST Moderna
CPT® code Short description Labeler
0092A ADM SARSCOV2 50 MCG/.5 ML2ND Moderna
0093A ADM SARSCOV2 50 MCG/.5 ML3RD Moderna
0094A ADM SARSCOV2 50MCG/0.5 MLBST Moderna
0111A ADM SARSCOV2 25MCG/0.25ML1ST Moderna
0112A ADM SARSCOV2 25MCG/0.25ML2ND Moderna
0113A ADM SARSCOV2 25MCG/0.25ML3RD Moderna
91300 SARSCOV2 VAC 30MCG/0.3ML IM Pfizer
91301 SARSCOV2 VAC 100MCG/0.5ML IM Moderna
91305 SARSCOV2 VAC 30 MCG TRS-SUCR Pfizer
91306 SARSCOV2 VAC 50MCG/0.25ML IM Moderna
91307 SARSCOV2 VAC 10 MCG TRS-SUCR Pfizer
91308 SARSCOV2 VAC 3MCG TRS-SUCR Pfizer
91309 SARSCOV2 VAC 50MCG/0.5ML IM Moderna
91311 SARSCOV2 VAC 25MCG/0.25ML IM Moderna
HCA revised the short descriptions for the following COVID vaccine procedure codes in the Apple Health (Medicaid) COVID-19 vaccine clinical policy, replacing “B“ with “A:”
CPT® code Short description Labeler
0124A ADM SARSCV2 BVL 30MCG/.3ML BA Pfizer
0134A ADM SARSCV2 BVL 50MCG/.5ML BA Moderna
0144A ADM SARCV2 BVL 25MCG/.25ML BA Moderna
0154A ADM SARSCV2 BVL 10 MCG/0.2ML BA Pfizer
0164A ADM SRSCV2 BVL 10MCG/0.2ML BA Moderna
0174A ADM SARSCV2 BVL 3MCG/0.2ML BA Pfizer
HCA revised the Apple Health (Medicaid) COVID-19 vaccine clinical policy. See HCA’s Provider billing guides and fee schedules, under COVID-19, Policies and billing guidance.
COVID-19 Fee Schedule
HCA revised the Emergency COVID-19 Fee Schedule. See HCA’s Provider billing guides and fee schedules, under COVID-19.
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