G0315 Insurance Policy Changes

NC Medicaid COVID-19 Vaccine Guidelines for 2026-2027

NC Medicaid updated its 2026-2027 COVID-19 vaccine coverage guidelines, introducing new vaccine formulations (targeting JN.1/LP.8.1 lineages) with updated NDC codes, CPT codes, and age-specific coverage criteria. Key billing changes include mandatory use of new vaccine CPT codes (91319, 91320, 91321, 91322, 91323, 91304), updated ICD-10 code Z23, new HCPCS counseling codes (G0310, G0312, G0315) effective since October 1, 2024, and pharmacy reimbursement for COVID-19 vaccines at point-of-sale for beneficiaries ages 3 and older effective January 1, 2025. The CG modifier must be appended to all COVID-19 vaccine and administration claims submitted by pharmacies, and the EP modifier applies to beneficiaries under age 21.