HCPCS Code Q5122: Injection, Pegfilgrastim-apgf (Nyvepria®), Biosimilar, 0.5 mg

## **Documentation requirements** When billing for HCPCS Code Q5122 (Injection, pegfilgrastim-apgf, Nyvepria®, biosimilar, 0.5 mg), providers must maintain thorough and accurate documentation to support claims. Medicare administrative contractors (MACs) and other payers may deny coverage if supporting details are missing or incomplete. Key documentation requirements include: - Patient information: Record patient demographics and clinical details that establish the medical necessity for the injection. - Diagnosis and clinical rationale: Clearly document the cancer type, chemotherapy regimen, and the prophylactic intent to reduce the incidence of febrile neutropenia. - Drug details: Specify that the substance administered was pegfilgrastim-apgf (Nyvepria®), the biosimilar drug, including the strength, dosage, and total units billed (0.5 mg per unit). - Administration details: Include the date of service, route (subcutaneous injection), site of administration, and any modifiers used. - Physician orders: Maintain signed and dated physician orders showing the intent for therapeutic or prophylactic use. - Supporting notes: Document treatment progress, patient tolerance to chemotherapy and diagnostic injection, and any adverse reactions. - Billing accuracy: Ensure the claim reflects the correct HCPCS code (Q5122), units, and payer-specific requirements, avoiding common errors like incorrect code substitution. Proper documentation supports compliance with CMS guidelines, ensures correct reimbursement under Medicare Part B, and helps avoid billing delays or denials.

## **Q5122 billing requirements** - Report HCPCS code Q5122 for each 0.5 mg unit of pegfilgrastim-apgf biosimilar administered subcutaneously. For example, a 6 mg dose should be billed as 12 units. Accurate unit reporting ensures proper reimbursement and avoids billing errors related to under- or over-reporting doses. - Coverage began January 1, 2021, under Medicaid and NC health choice physician-administered drug programs (NC Medicaid, Division of Health Benefits, 2021). - Use CPT 96372 (therapeutic, prophylactic, or diagnostic subcutaneous or intramuscular injection) to report the administration solution separately from the drug code. For hospital outpatient claims, include Revenue Code 0636 (drugs requiring specific identification). Note that Revenue Code 0636 should be used consistently for pegfilgrastim-apgf in outpatient hospital settings to ensure proper processing of drug charges (Pfizer Inc., 2021). - If any portion of single-use syringes is discarded, append the JW modifier (discarded drug) or JZ modifier (no discarded drug) as required by Medicare rules (Pfizer Inc., 2021). - Medicaid, particularly NC Medicaid, often requires inclusion of the 11-digit NDC (e.g., 00069-0324-01) when submitting Q5122 claims (Pfizer Inc., 2021). - Clear alignment with payer-specific billing policies and precise claims submission, including correct dosage units, applicable modifiers, accurate NDC reporting, and matching the billed code to the biosimilar actually administered, is essential to ensure accurate reimbursement and minimize the risk of claim denials or delays.

## **Other relevant codes** - J2506 — Injection, pegfilgrastim, excludes biosimilar, 0.5 mg. - Q5108 — Injection, pegfilgrastim-jmdb (Fulphila®), biosimilar, 0.5 mg.

## **References** NC Medicaid, Division of Health Benefits. (2021, January 5). Pegfilgrastim-APGF injection, for subcutaneous use (NyvepriaTM) HCPCS Code Q5122: Billing guidelines. (2021, January 5). https://medicaid.ncdhhs.gov/blog/2021/01/05/pegfilgrastim-apgf-injection-subcutaneous-use-nyvepria%E2%84%A2-hcpcs-code-q5122-billing Pfizer Inc. (2021). Nyvepria billing and coding guide. In Nyvepria [Report]. https://www.pfizeroncologytogether.com/files/NYVEPRIA_Billing_and_Coding_Guide.pdf