Provider Alert! COVID-19 Monoclonal Antibody Therapy Procedure Code Update
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 |
Reference
Next steps for providers: Providers should share this communication with their staff.
If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.
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