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COVID-19 roster billing for Part B providers

First Coast has created a new standard roster form for COVID-19 vaccination and mAb infusion. This form is like the existing flu and pneumococcal forms and is available to providers through our website. We also provide an example below of the modified CMS-1500 (02/12) claim form, which serves as the cover document for the roster claim. 

Use of this form simplifies roster billing for the COVID-19 vaccinations and mAb infusions:

  • The roster form allows up to five patients per page and can be submitted duplex (two-sided) to allow 10 patients per page.
  • Up to 10 pages per modified CMS-1500 (02/12) claim form will be accepted and scanned using Optical Character Recognition (OCR) technology.
  • Only bill for the vaccine administration codes when you submit claims to Medicare; don't include the vaccine product codes when vaccines are free.

Claims will be returned as unprocessable when this new standard roster form (linked below) is not submitted with the modified CMS-1500 (02/12) claim form or if the roster form/CMS-1500 claim form is incomplete.

Coding for COVID-19

For information on coding for COVID-19 vaccines and monoclonal antibodies review the COVID-19 vaccine and monoclonal antibody billing article for Part B providers.

COVID-19 roster billing

Roster bills can be submitted on paper or electronically. If billing for both COVID-19 vaccinations and mAb infusions, these need to be submitted on separate claims. Do not bill for the other service on the same claim. Do not use roster billing for a single beneficiary. 

Modified CMS-1500 (02/12) claim form instructions

Complete a modified CMS-1500 (02/12) claim form containing the information in the table below to serve as a cover document to the roster bill.

Item number Information to enter
1 -- Type of insurance "X" in Medicare block
2 -- Patient's name Enter "SEE ATTACHED ROSTER"
11 -- Insured's policy group or Federal Employees' Compensation Act (FECA) Number Enter "NONE"
20 -- Outside lab "X" in the NO block
21 -- Diagnosis or nature of illness or injury

For vaccine billing:

Line A: Enter "Z23"

Enter "0" for ICD Indicator between dotted lines

 

For mAb billing:

Line A: Enter appropriate diagnosis coded to highest level of specificity (U071 – use as appropriate)

Enter "0" for ICD Indicator between dotted lines
24B -- Place of service (POS)

Enter "60" 

Note: POS code "60" must be used for roster billing
24D -- Procedure, services, or supplies

Enter the appropriate COVID-19 vaccine or mAb infusion administration code

  • Note; Medicare will not provide payment for the COVID-19 vaccine or mAb products that healthcare professionals receive for free, as will be the case upon the product's initial availability in response to the COVID-19 PHE. Providers should not bill for product if it is received for free.
24E -- Diagnosis pointer (Code) Enter "A"
24F -- Charges

List charge for each service *Not total for all patients

If no charge, enter "$0.00"

Note: Medicare will not provide payment for the COVID-19 vaccine or mAb products that healthcare professionals receive for free, as will be the case upon the product's initial availability in response to the COVID-19 PHE. Providers should not bill for product if it is received for free.
27 -- Accept assignment? Enter "X" in YES block
29 -- Amount paid Enter "$0.00"
31 -- Signature of physician or supplier Entity's representative must sign
32 -- Service facility location information Name, address and ZIP of location where services were rendered
32a -- Service facility location number National Provider Identifier (NPI) of service facility
33 -- Billing provider information & phone number Enter billing provider information and phone number
33a -- Billing provider NPI Enter the NPI of the billing provider or group

 

Attach the standard COVID-19 Vaccines or Monoclonal Antibody Infusion Roster Form with the following information completed:

  • Provider's name and NPI
  • Date of service
  • Beneficiary
    • Medicare number
    • Date of birth
    • Signature or stamped "signature on file"
    • Name (last, first, middle initial)
    • Sex
    • Address 

Note: If the beneficiary's actual signature cannot be obtained, the phrase "signature on file" can be used if the provider has a signed authorization on file from the beneficiary to bill Medicare for services.

Roster forms

First Coast houses the roster forms on the Forms page of our website, under the "Immunization roster billing" section.

Returned claims

If a claim returns for OCR references, you will receive notification through your normal provider voucher or reconciliation file with the appropriate returned information. It is your responsibility to verify that all information is complete before resubmitting the claim.

 

References