C9054 Injection, lefamulin — HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS C9054: Injection, lefamulin (Xenleta), 1 mg

HCPCS Level II code C9054 denotes administration of lefamulin (Xenleta) as an injectable product measured per 1 mg. This code captures use of a newer pleuromutilin-class antibiotic indicated for certain bacterial infections where parenteral therapy is required, making it relevant for acute care settings and antimicrobial stewardship programs. Nationally, accurate coding of high-cost, novel injectables affects payment, utilization tracking, and formulary management across public and commercial payers.

Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of what the code represents, typical sites of service, and the clinical context for injectable lefamulin use. The publication provides benchmarks where available, notes on payer coverage patterns, and relevant policy or coding updates that influence billing and reimbursement workflows.

The report is intended for billing managers, pharmacy directors, clinicians involved in inpatient and outpatient parenteral therapy, and policy analysts. It summarizes coding guidance, payer considerations, and operational implications for using HCPCS Level II code C9054 for lefamulin injections, and points to areas where additional documentation or payer-specific policy review may be required. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareC9054HCPCS Level IIinjectionlefamulinXenletainjectable antibioticoutpatient infusionhospital outpatientdrug administration

Billing Code Overview

HCPCS Level II code C9054 represents Injection, lefamulin (Xenleta), 1 mg. This code is used to report administration of the antibiotic lefamulin in a parenteral injectable form. The service type is an injectable antimicrobial medication administration, and the typical site of service is outpatient infusion centers, hospital outpatient departments, emergency departments, or other clinical settings where parenteral antibiotics are administered.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A patient presents to an outpatient infusion clinic or emergency department with a diagnosed or strongly suspected community‑acquired bacterial pneumonia (CABP) or acute bacterial skin and skin structure infection (ABSSSI) where intravenous antibiotic therapy is indicated and oral therapy is not appropriate. The patient is evaluated by an advanced practice provider or physician, including history, physical exam, and relevant diagnostics (chest radiograph, pulse oximetry, basic labs). After clinician decision to administer parenteral lefamulin (C9054, injection, lefamulin 1 mg), the patient is escorted to the treatment area, IV access or intramuscular injection is prepared per facility protocol, dose is calculated based on the provider order (commercial formulation), and medication is prepared by pharmacy. The medication is administered under nursing supervision with monitoring for infusion‑related reactions and vital sign checks per policy. Documentation includes indication, dose, route, lot number, start and stop times, patient tolerance, and any adverse events. Billing uses HCPCS Level II code C9054 for the lefamulin product, with supporting facility and provider claims as appropriate. Typical sites of service include outpatient infusion center, emergency department, hospital inpatient ward, or observation unit depending on illness severity and disposition.

Coding Specifications

Modifier	Description	When to Use
`25`

HCPCS C1719: Brachytherapy Source, Iridium-192, Non-Stranded

HCPCS-C9762-CARDIAC-MRI-SEGMENTAL-DYSFUNCTION-STRAIN-IMAGING

HCPCS Level II C9762: Cardiac MRI for Morphology and Function with Strain

HCPCS-C1735-RENAL-DENERVATION-RF-INTRAVASCULAR-CATHETER

HCPCS C1735: Renal Denervation RF Intravascular Catheter

HCPCS-C8907-BILATERAL-BREAST-MRI-NO-CONTRAST

HCPCS Level II C8907: Magnetic Resonance Imaging Without Contrast, Breast; Bilateral

HCPCS-C9069-BELANTAMAB-MAFODONTIN-INJECTION-0-5-MG

HCPCS Level II C9069: Injection, belantamab mafodontin-blmf, 0.5 mg

HCPCS-C7504-PERCUTANEOUS-VERTEBROPLASTY-CERVICOTHORACIC-LUMBOSACRAL

HCPCS C7504: Percutaneous Vertebroplasty, Cervicothoracic/Lumbosacral

HCPCS-C9025-RAMUCIRUMAB-INJECTION-5MG

HCPCS C9025: Injection, ramucirumab, 5 mg

HCPCS-C7554-CYSTOURETHROSCOPY-BLUE-LIGHT-FLUORESCENT-IMAGING

HCPCS C7554: Cystourethroscopy with Blue Light Fluorescent Imaging

HCPCS-C9055-BREXANOLONE-INJECTION-1MG-INFUSION-THERAPY

HCPCS Level II C9055: Injection, brexanolone, 1mg

HCPCS-C9056-GIVOSIRAN-INJECTION-0-5-MG

HCPCS Level II C9056: Injection, givosiran, 0.5 mg

Showing 1–10 of 603

Taxonomy Code	Specialty	Notes
`208000000X`	Infectious Disease Physician	Primary specialty for complex antibiotic selection, inpatient consultation, and stewardship oversight.
`207Q00000X`	Emergency Medicine Physician	Commonly initiates parenteral antibiotics in acute presentations in the ED.
`363A00000X`	Nurse Practitioner	Frequent ordering and administration oversight in outpatient infusion centers and clinics.
`363L00000X`	Physician Assistant	Orders and documents administration in various outpatient and inpatient settings.
`222N00000X`	Clinical Pharmacist	Prepares, verifies dosing, and provides stewardship review in hospital and infusion settings.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`J18.9`	Pneumonia, unspecified organism	Common indication for parenteral lefamulin when bacterial pneumonia requires IV therapy.
`J15.9`	Unspecified bacterial pneumonia	Direct bacterial pneumonia diagnosis where targeted IV antibiotic therapy such as lefamulin may be used.
`J13`	Pneumonia due to Streptococcus pneumoniae	Pathogen‑specific pneumonia where lefamulin activity against common respiratory pathogens is clinically relevant.
`L03.90`	Cellulitis, unspecified	Acute bacterial skin and skin structure infections (ABSSSI) that may require parenteral antibiotic administration.
`A49.9`	Bacterial infection, unspecified	General bacterial infection diagnosis when specific site or organism is not yet identified but IV antibiotics are needed.
`R65.20`	Severe sepsis without septic shock	Systemic infection severity that can necessitate inpatient IV antibiotic therapy including lefamulin as part of regimen where appropriate.
`Z51.89`	Encounter for other specified aftercare	Use for outpatient antibiotic administration visits or infusion follow‑up encounters when applicable.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`96365`	Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour	Used when lefamulin is administered as an IV infusion and billing for the infusion time is applicable for facility or professional claims.
`96366`	Intravenous infusion, each additional hour (List separately in addition to code for primary service)	Used when IV infusion for the antibiotic extends beyond the initial hour and additional infusion time is billed.
`96372`	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular	Used when lefamulin is administered via intramuscular injection instead of intravenous infusion.
`36415`	Collection of venous blood by venipuncture	Used when labs (e.g., cultures, BMP) are obtained to guide antibiotic therapy prior to or during administration.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity	Used when an outpatient E/M visit documents assessment and decision to initiate parenteral lefamulin and is billed with appropriate modifiers when performed same day.
`99285`	Emergency department visit for the evaluation and management of a patient, high severity	Used when the decision to administer IV lefamulin occurs in the emergency department for a severely ill patient requiring detailed ED services.

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