Announcement

  • Announcement is also available in Portable Document Format (PDF)

Billing Allowances for Nirsevimab and Abrysvo Provided by Article 29-I VFCA Health Facilities

February 13, 2024

To: Article 29-I VFCA Health Facilities (29-Is) and Medicaid Managed Care Plans (MMCPs) including Mainstream Managed Care and HIV Special Needs Plans

New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) are providing coverage for the administration of Nirsevimab, a monoclonal antibody preparation for the prevention of Respiratory Syncytial Virus (RSV), and Abrysvo, a Respiratory Syncytial Virus (RSV) vaccine approved for use in pregnant individuals at 32 to 36 weeks gestation . Effective October 1, 2023, NYS has made Nirsevimab available through the Vaccines for Children (VFC) Program. Effective December 18, 2023, NYS has opened ordering of Abrysvo through the VFC Program.

29-I Health Facilities who participate in the VFC Program may provide and bill for the administration of Nirsevimab and Abrysvo. To be reimbursed for the administration of Nirsevimab or Abrsysvo through the 29-I Other Limited Health Related Services Fee Schedule, 29-Is must be enrolled in the VFC Program. 29-Is are permitted to bill for the administration of Nirsevimab/Abrysvo as a 29-I Other Limited Health Related Service using the following rate code, procedure code, and RSV CPT code listed below:

  • Rate Code 4599; AND
  • Procedure code 90460: Administration of FREE vaccine; AND
  • CPT code 90380: (Nirsevimab) Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use; OR
  • CPT Code 90381: (Nirsevimab) Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use; OR
  • CPT Code 90678: (Abrysvo) Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use

Additional information on Medicaid coverage of Nirsevimab can be found in New York State Medicaid Update - September 2023 Volume 39 - Number 14 (ny.gov). Additional information on Medicaid coverage for Abrysvo will be included in an upcoming Medicaid Update which will be viewable on the DOH Website. Information on billing for the administration of vaccines/toxoids though the VFC Program by 29-Is, including information on required billing modifiers, can be found in the 29-I Health Facility Billing Manual. CDC Guidance on the use of these substances through the VFC program can be found here.

Any questions on this announcement can be sent to BH.Transition@health.ny.gov.