HCPCS Code Q5104

Official Description

Injection, infliximab-abda, biosimilar, (renflexis), 10 mg

Short Descr	Injection, renflexis
Related Drugs	Renflexis
Coverage	Special coverage instructions apply
Pricing Indicator(s)	51 – Drugs
MPI	A – Not applicable, as HCPCS priced under one methodology
ASC Payment Group Code	YY – 4/01/2018
Processing Note	PUB. 100-4, CHAPTER 17.
BETOS	O1E – Other drugs
TOS Code(s)	1 – Medical care
Added Date	4/1/2018
Status Code	Excluded from Physician Fee Schedule by Regulation
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	9 - Not Applicable
Multiple Procedures (51)	9 - Concept does not apply.
Bilateral Surgery (50)	9 - Concept does not apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	9 - Concept does not apply.
Co-Surgeons (62)	9 - Concept does not apply.
Team Surgery (66)	9 - Concept does not apply.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Nonpass-Through Drugs and Nonimplantable Biologicals, Including Therapeutic Radiopharmaceuticals
ASC Payment Indicator	Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate.
MUE	150
MUE	0
OTS Orthotic	No

JZ	Zero drug amount discarded/not administered to any patient
JW	Drug amount discarded/not administered to any patient
JA	Administered intravenously
EJ	Subsequent claims for a defined course of therapy, e.g., epo, sodium hyaluronate, infliximab
GY	Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
AQ	Physician providing a service in an unlisted health professional shortage area (hpsa)
Q6	Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
JG	Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes
59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
KX	Requirements specified in the medical policy have been met
TB	Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes
GW	Service not related to the hospice patient's terminal condition
UD	Medicaid level of care 13, as defined by each state
GA	Waiver of liability statement issued as required by payer policy, individual case
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
76	Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.