C9061 teprotumumab — HCPCS Reimbursement & Policy | OpenPayer

Summary & Overview

HCPCS C9061: Injection, teprotumumab-trbw, 10 mg

HCPCS Level II code C9061 identifies the injectable biologic product teprotumumab-trbw in 10 mg units. As a drug-specific HCPCS Level II code, it facilitates billing for administration and product reporting for this targeted therapy used in specialty infusion settings. Nationally, accurate coding for high-cost biologics like teprotumumab-trbw is important for claims processing, patient access, and payer coverage determinations.

Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of what the code represents, the typical service setting, and which major payers are relevant for coverage and billing considerations. The publication also outlines benchmarks and policy-relevant topics: payer coverage policies, billing and documentation expectations, and common modifiers used in practice. When payer-specific coverage details or utilization data are not available in the input, the publication notes that data is not available in the input.

This overview serves clinicians, billing professionals, and policy analysts seeking a national-level reference for coding and administrative handling of HCPCS Level II code C9061 for teprotumumab-trbw injections.

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Billing Code Overview

HCPCS Level II code C9061 describes Injection, teprotumumab-trbw, 10 mg. This code represents a medication administration service for a biologic agent provided as an injectable formulation, with the unit defined per 10 mg of the product.

Service type: Injection of a biologic therapeutic agent
Typical site of service: Infusion clinic or outpatient office where parenteral biologic therapies are administered

Clinical & Coding Specifications

Clinical Context

A 45-year-old patient with active, progressive thyroid eye disease (thyroid-associated ophthalmopathy) presents to an outpatient specialty infusion clinic for administration of teprotumumab-trbw. The medication is supplied and billed per 10 mg units as C9061. The patient undergoes eligibility verification and prior authorization with their insurer (examples: Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, Medicare). On the day of service the patient is triaged by nursing for vital signs, baseline visual acuity, intraocular pressure, and a targeted history for recent infections or hypersensitivity. A physician or advanced practice provider documents indication, consent, and reviews prior response to therapy and contraindications.

The infusion team prepares the appropriate dose based on the product prescribing information (weight-based dosing), calculates the number of C9061 units required, compounds and verifies the infusion, and administers via IV infusion per protocol. Observation for infusion reactions occurs for the recommended period; nursing documents infusion start/stop times and any medications administered for adverse events. If an infusion is interrupted, reduced, or discontinued, an appropriate modifier may be appended to the claim. Billing captures the number of C9061 units administered, facility or clinic place of service, and any applicable professional services (e.g., infusion supervision) using related CPT codes and provider taxonomy for ophthalmology or infusion services.

Coding Specifications

Modifier	Description

Related Codes

HCPCS-C9475-NECITUMUMAB-INJECTION-1MG

HCPCS C9475: Injection, necitumumab, 1 mg

HCPCS-C2616-YTTRIUM-90-BRACHYTHERAPY-SOURCE-NON-STRANDED

HCPCS C2616: Yttrium-90 Brachytherapy Source, Non-Stranded

HCPCS-C9601-DRUG-ELUTING-INTRACORONARY-STENT-ADDITIONAL-BRANCH

HCPCS C9601: Drug‑Eluting Intracoronary Stent, Additional Branch

HCPCS-C2630-ELECTROPHYSIOLOGY-DIAGNOSTIC-ABLATION-COOL-TIP-CATHETER

HCPCS C2630: Electrophysiology Diagnostic/Ablation Cool-Tip Catheter

HCPCS-C1839-IRIS-PROSTHESIS-IMPLANT

HCPCS Level II C1839: Iris Prosthesis

HCPCS-C8957-PROLONGED-INFUSION-INITIATION-PORTABLE-IMPLANTABLE-PUMP

HCPCS C8957: Initiation of Prolonged IV Infusion Using Portable or Implantable Pump

HCPCS-C9098-CILTACABTAGENE-AUTOLEUCEL-BCMA-CAR-T-THERAPY

HCPCS C9098: Ciltacabtagene Autoleucel, BCMA-Directed CAR T Therapy

HCPCS-C9091-SIROLIMUS-PROTEIN-BOUND-PARTICLES-INJECTION-1MG

HCPCS C9091: Injection, sirolimus protein-bound particles, 1 mg

HCPCS-C7538-LEFT-VENTRICULAR-PACING-LEAD-PLACEMENT-WITH-GENERATOR-INSERTION

HCPCS C7538: LV Pacing Lead Placement During Pacemaker/ICD Generator Insertion

HCPCS-C1820-RECHARGEABLE-NEUROSTIMULATOR-GENERATOR

HCPCS C1820: Implantable Neurostimulator Generator, Rechargeable

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`22`	Increased procedural services	Use when work required to administer or manage the infusion is substantially greater than usual (extensive complications or unusually prolonged management documented).
`23`	Unusual anesthesia	Use if unusual anesthesia unrelated to the procedure is provided for infusion-related management (rare for IV infusions).
`52`	Reduced services	Use when teprotumumab infusion is partially reduced or not completed as planned but still performed.
`53`	Discontinued procedure	Use when the infusion is started but terminated due to patient condition or adverse reaction before completion.
`54`	Surgical care only	Not typically applicable; use when only surgical portion provided and postoperative care billed separately (rare for this drug).
`55`	Postoperative management only	Not typically applicable; use when only post-op care is billed (rare for infusion).
`56`	Preoperative management only	Not typically applicable; use when only pre-op care billed (rare for infusion).
`62`	Two surgeons	Use when two surgeons of different specialties are documented as providing concurrent surgical services related to the patient’s care (rare for this infusion).
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery	Use if an advanced practice provider assists with a procedure related to the infusion visit as documented.
`CO`	Left and right or other paired organ/another area	Use when bilateral or paired procedures are billed and modifier correctly reflects laterality when applicable.
`CQ`	Service delivered under an alternative payment demonstration	Use for claims subject to specified payment demonstration projects when applicable.
`FX`	Primary surgical team changed intraoperatively	Use if primary team changes during procedure; rarely applicable to infusion.
`FY`	Removed by Medicare, historic use	Not typically used; included in payer-specific contexts only if mandated.
`QK`	Medical direction of two, three, or four assistants	Use when physician-directed assistants meet criteria; rarely relevant to infusion-only visits.
`QX`	CRNA service with medical direction by physician	Use when a CRNA provides anesthesia under direction; uncommon for outpatient infusion.
`QY`	Medical direction of one CRNA by an anesthesiologist	Use when applicable to anesthesia services associated with the visit; uncommon for this drug.
`SH`	Speech-language pathology services within a rehab program	Not applicable to this infusion visit; listed for completeness where program billing applies.
`SJ`	Audiology services within a rehab program	Not applicable to this infusion visit.

Taxonomy Code	Specialty	Notes
`2080P0206X`	Ophthalmology	Specialists who evaluate and manage thyroid eye disease and order/administer teprotumumab.
`363L00000X`	Infusion Therapy	Providers or clinical programs specializing in infusion administration and monitoring.
`363A00000X`	Ambulatory infusion center	Facility taxonomy for outpatient infusion delivery sites.
`207Q00000X`	Physician Assistant	Midlevel providers who may perform evaluation and management and participate in infusion care under supervision.
`363LF0200X`	Pharmacy - Infusion/Parenteral Therapy	Pharmacists involved in drug preparation, compounding, and verification.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`E05.00`	Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm	Thyroid dysfunction often associated with autoimmune Graves disease; thyroid eye disease commonly occurs in this population and may qualify for teprotumumab.
`E05.01`	Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm	Acute severe thyroid state; relevant when assessing overall disease severity although not a direct indication for teprotumumab.
`H06.2`	Exophthalmos	Directly describes the clinical manifestation of proptosis targeted by teprotumumab therapy.
`H05.22`	Orbital inflammation, bilateral	Orbital inflammation is part of thyroid eye disease spectrum and relates to indication for targeted therapy.
`M35.0`	Sicca syndrome [Sjogren]	Autoimmune comorbidities may coexist and affect management and screening before systemic biologic therapy.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`96365`	Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour	Used to report the initial infusion administration time for teprotumumab when billed separately from the drug product.
`96366`	Intravenous infusion, each additional hour (List separately in addition to code for primary service)	Used when infusion time extends beyond the first hour and additional time-based billing is appropriate.
`96413`	Chemotherapy administration, intravenous infusion technique; up to 1 hour, requiring constant physician or other qualified health care professional supervision	Occasionally used for biologic infusion administration requiring higher-level supervision protocols per payer guidance.
`96360`	Intravenous infusion, hydration; initial, 31 minutes to 1 hour	Used when IV hydration is separately administered during the infusion visit.
`96372`	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular	May be used for ancillary injections (e.g., medications to treat infusion reaction) given during the visit.