Summary & Overview
HCPCS C9036: Injection, patisiran 0.1 mg
HCPCS Level II code C9036 denotes a dose-based billing unit for patisiran (0.1 mg), a targeted RNAi therapeutic administered by injection. The code is used to report the drug itself as a separately payable injectable product in outpatient and ambulatory infusion settings. Nationally, biologic and specialty drug coding matters for accurate reimbursement, utilization tracking, and benefit design, particularly for high-cost, infrequently administered therapies.
Key payers in typical analyses include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context and service settings, benchmark considerations for dose-based HCPCS reporting, relevant payer coverage landscapes, and common billing and claim submission topics. The publication summarizes what providers and billing professionals need to know about unitization, typical sites of service, and national policy drivers that affect specialty injectables.
This piece covers benchmarks and payer policy themes, clinical context for patisiran administration, and operational implications for outpatient infusion centers and ambulatory clinics. Data not available in the input will be noted explicitly in relevant sections.
Billing Code Overview
HCPCS Level II code C9036 represents Injection, patisiran, 0.1 mg. This code denotes a dose-based billing unit for the medication patisiran, an RNA interference therapeutic used for hereditary transthyretin-mediated (hATTR) amyloidosis and related indications.
Service type: Injection (pharmaceutical administration)
Typical site of service: Outpatient infusion or ambulatory clinic
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult with hereditary transthyretin-mediated (hATTR) amyloidosis presenting with polyneuropathy and/or cardiomyopathy who receives intravenous infusion of patisiran as part of maintenance therapy. The clinical workflow includes: referral by a neurology or cardiology specialist, baseline assessment (neurologic exam, functional scales, laboratory studies including liver function tests), infusion center scheduling, verification of payer authorization, preparation of C9036 (patisiran dose measured as 0.1 mg units) by pharmacy in a sterile compounding area, pre-infusion vital signs and allergy check, intravenous infusion administration in an outpatient infusion suite with monitoring for infusion-related reactions, post-infusion observation for delayed reactions, documentation of dose administered and lot numbers, and follow-up neurology/cardiology visits for efficacy and safety monitoring. Typical site of service is an outpatient infusion center or hospital outpatient department. Typical service type is a specialty drug infusion for a disease-modifying oligonucleotide therapy delivered intravenously.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
59 | Distinct procedural service | When another unrelated procedure is performed on the same day and distinct from the infusion service |