Provider Alert! COVID-19 Monoclonal Antibody Therapy Procedure Code Update

By Texas Children's Health Plan OB/GYNs, Office Managers, Primary Care Providers, Provider Alert, Specialists antibodies, COVID, COVID-19, Emergency Use Authorization, monoclonal, provider alert, provider alerts 0 Comments

Date: July 19, 2021

Attention: All Providers

Effective Date for Procedure code Q0244 is June 3, 2021

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan would like to inform network providers that Texas Medicaid has revoked the Emergency Use Authorization (EUA) of bamlanivimab effective April 30, 2021, when administered alone for treatment of mild-to-moderate COVID-19. The FDA determined that the benefits of bamlanivimab no longer outweighed the risks. Bamlanivimab/etesevimab is still authorized.

New for June 24, 2021: for dates of service on or after May 26, 2021, the reimbursement rates for COVID-19 Monoclonal Antibody Therapy procedure codes M0247 and Q0247 will be updated for Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program.

Monoclonal antibodies are used to treat COVID-19 and should be administered within 10 days of symptom onset. Qualifications to receive these medications include the following:

Mild to moderate coronavirus disease (COVID-19) with a diagnosis of U07.1
Patients twelve years old and older
Patients with a weight of at least 40 kg or 88 pounds
Patients that are at a high risk of progressing to severe COVID-19 or requiring hospitalization

These medications are not recommended for patients that have been hospitalized due to COVID-19 or require oxygen therapy.

How this impacts providers: The following codes are set up as payable. Bamlanivimab has been removed.

Drug Name	Procedure Code	Administration Code	Date of Service Allowable (On/After)	Age / Weight / Diagnosis Restrictions
Casirivmab / Imdevimab	Q0243 Q0244	M0243	November 21, 2020 June 3, 2021 for Q0244	Diagnosis: U07.1 – Mild to Moderate COVID-19 Diagnosis: U07.1 – Mild to Moderate COVID-19
Bamlanivimab / Etesevimab	Q0245	M0245	February 9, 2021
Sotrovimab	Q0247	M0247	May 26, 2021	Age > 12 years Weight > 40 kg (88 lbs) Diagnosis: U07.1 – Mild to Moderate COVID-19

Procedure codes M0243, M0245, and M0247 are a benefit for the following providers and places of service:

Place of Services	Provider Type
Office	Physician assistant, nurse practitioner, clinical nurse specialist, physician (D.O), physician (M.D.), physician group (D.O.s only), clinic/group practice
Outpatient hospital	Hospital (long-term, limited, or specialized care), hospital (private full care), hospital (private, outpatient service, emergency care only)
Nursing home – skilled nursing facility/intermediate care facility (SNF/ICF)	Physician (D.O), physician (M.D.), physician group (D.O.s only), clinic/group practice
Nursing home – extended care facility (ECF)	Physician (D.O), physician (M.D.), physician group (D.O.s only), clinic/group practice