HCPCS C9257: Injection, Bevacizumab, 0.25 mg (intravitreal)

Obtain a list of the different documentation and billing requirements needed to properly use and bill for HCPCS code C9257.

Use Code

## **What is HCPCS code C9357?** HCPCS code C9257 represents a 0.25 mg dose of bevacizumab (Avastin®) administered via intravitreal injection. Bevacizumab is a monoclonal antibody that inhibits vascular endothelial growth factor (VEGF). It is used to treat various conditions, and in ophthalmology, it is frequently used off-label via intravitreal injection to treat conditions involving abnormal blood vessel growth in the eye. More specifically, the medication is typically used for ophthalmic indications such as diabetic macular edema and wet age-related macular degeneration. This low-dose formulation is designated specifically for use in ophthalmologic settings, most often billed in ambulatory surgical centers (ASC) or hospital outpatient environments. This code is typically reported when the drug is administered in a facility setting, such as an Ambulatory Surgical Center (ASC) or a hospital outpatient department (sometimes referred to as the Part A Medicare Administrative Contractor (MAC)). Do note, in addition, that this code is used to bill for the drug product itself, not the professional service of the injection.

## **HCPCS code C9257 documentation requirements** Accurate and complete documentation is crucial for appropriate reimbursement and to demonstrate medical necessity. Key documentation elements for C9257 and the associated procedure typically include: - **Patient record**: The medical record must clearly document the patient's condition and the reason for the treatment. - **Medical necessity**: Documentation must support the medical necessity for the bevacizumab injection based on a covered diagnosis. Common ophthalmologic indications often include neovascular (wet) age-related macular degeneration (AMD), diabetic retinopathy macular edema, macular edema following retinal vein occlusion (RVO). - **Procedure details**: Details on the procedure, such as the following, must be included in the patient's medical records date and time of service; site of injection (e.g., right eye (OD), left eye (OS), or bilateral); drug name, strength, and dosage administered (0.25 mg per unit of C9257); method of administration (intravitreal injection), etc. - **CPT code and modifiers**: For providers billing Part A (ASC or hospital outpatient), C9257 must be used for bevacizumab intravitreal injections—accompanied by correct CPT coding (e.g., CPT 67028) with appropriate modifiers (RT, LT, 50) for laterality - **Adherence to payer policy**: The documentation should align with any specific requirements outlined in the payer's Local Coverage Determination (LCD) or national policy.

## **C9257 billing requirements** To prevent the denial of claims, the following requirements must be considered: - **Site of service**: Facility setting (e.g., ASC, hospital outpatient). - **Drug code**: C9257 (Injection, bevacizumab, 0.25 mg) is used to bill for the drug product. - **Procedure code**: The service of the intravitreal injection should be coded using the appropriate CPT code, typically 67028 (Intravitreal injection of a pharmacologic agent). - **Units**: Bill one unit of C9257 for the ophthalmologic dose (0.25 mg). - **Modifiers**: An appropriate site modifier is generally required to specify the eye treated: -RT (Right side), -LT (Left side), or -50 (Bilateral procedure, depending on payer rules). Claims without a site modifier may be returned. - **Diagnosis codes**: Claims must include the appropriate ICD-10-CM code(s) that support the medical necessity of the treatment. - **Prior authorization**: Generally, the code doesn't require prior authorization (PA) before administering and billing for bevacizumab, but some insurance payers may require it.

## **Other relevant codes** - **J9035**: Injection, bevacizumab, 10 mg (non-ophthalmologic systemic use) - **Q5107**: Injection, bevacizumab-awwb, biosimilar, (MVASI), 10 mg - **Q5118**: Injection, bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg - **J7999**: Compounded drug, not otherwise classified

Frequently asked questions

C9257 (0.25 mg) is the code generally used by facilities (ASC, hospital outpatient) to bill for the drug product for ophthalmologic use. J9035 (10 mg) is the code typically used by office-based physicians (Part B MAC) to bill for the same drug, but the unit of measure is different, reflecting the dose drawn from the vial.

No. While bevacizumab is an FDA-approved cancer treatment, C9257 is specifically intended for the small-dose, ophthalmologic indications (like wet AMD, diabetic macular edema) when billed in a facility setting, as determined by Medicare and other payer policies.

Yes. If the injection is performed in both eyes during the same session, you generally bill the procedure code (e.g., 67028) and the drug code (C9257) on two separate lines—one for the right eye with modifier -RT and one for the left eye with modifier -LT. You would report one unit of C9257 per line, for a total of two units. Alternatively, some payers accept one line with the -50 bilateral modifier for the procedure code, but you should verify your payer's specific rule.