Provider Alert! Update to COVID-19 Monoclonal Antibody Therapy Administration Codes M0245 and M0246

Date: January 3, 2022

Attention: All Providers

Subject: Update to COVID-19 Monoclonal Antibody Therapy Administration Codes M0245 and M0246

Effective Date: Dates of service on or after December 3, 2021 for age range expansion

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: On December 3, 2021, the U.S. Food and Drug Administration revised the emergency use authorization (EUA) of bamlanivimab and etesevimab, (monoclonal antibody therapy). Bamlanivimab and etesevimab may now be administered together for the treatment of mild to moderate COVID-19 in all younger patients, including newborns, who have a positive COVID-19 test and are at high risk for progression to severe COVID-19, including hospitalization or death. The revision also authorizes use of monoclonal antibody therapy for post-exposure prophylaxis for prevention of COVID-19 in all pediatric patients, including newborns, at high risk of progression to severe COVID-19, including hospitalization or death. Previously, bamlanivimab and etesevimab were authorized  to be administered together for the treatment of mild to moderate COVID-19 in pediatric patients 12 years of age and older weighing at least 40kg/88lbs.

How this impacts providers: Effective for dates of service on or after December 3, 2021, the age range for codes M0245 and M0246 have been expanded from ages 12 years and older to ages 0 and older for monoclonal antibody therapy administration.

Texas Medicaid and CHIP providers may bill MCOs retroactively for COVID-19 monoclonal antibody therapy codes M0245 and M0246 for the expanded age range. MCOs must reprocess affected claims with these procedure codes with dates of service on or after December 3, 2021, and providers may receive an additional payment. TCHP will not require providers to appeal the claims to be paid unless they are denied for other reasons after the claims reprocessing is complete.

Effective for dates of service on or after September 16, 2021, diagnosis code Z20822, indicating possible exposure to COVID-19, was added as a payable diagnosis for procedure codes M0245 and M0246 for monoclonal antibody therapy administration. Providers may bill for COVID-19 monoclonal antibody therapy codes M0245 and M0246 with diagnosis code Z20822 on or after September 16, 2021. TCHP will reprocess affected claims with these procedure and diagnosis codes with dates of service on or after September 16, 2021, and providers may receive an additional payment.  Providers do not need to submit appeals unless they are denied for other reasons after the claims reprocessing is complete.

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.