Summary & Overview
HCPCS Level II C9074: Lumasiran Injection, 0.5 mg
HCPCS Level II code C9074 designates the 0.5 mg unit for lumasiran injection, a targeted therapy administered by injection. Nationally, accurate use of this code matters for clinical documentation, drug utilization tracking, and payer reimbursement for specialty pharmaceuticals delivered in outpatient settings. This code is relevant for clinicians, billing teams, and payers involved in managing rare-disease therapies.
Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of what C9074 denotes, the typical sites of service where it is billed, and which payers commonly adjudicate claims for this injectable product. The content also outlines the scope of benchmarks and policy context addressed in the publication: billing unit conventions for a 0.5 mg measure, common service-line implications for outpatient infusion or office-based administration, and payer coverage considerations at a national level.
The publication provides practical benchmarking information, summarizes notable policy updates affecting specialty drug billing, and situates C9074 within clinical and billing workflows for injectable therapies. Data not available in the input are noted where applicable.
Billing Code Overview
HCPCS Level II code C9074 represents Injection, lumasiran, 0.5 mg. This entry is used to report administration of the specified biologic agent in a single 0.5 mg dosing unit. The service type is drug administration/injection, and the typical site of service is an outpatient clinic or ambulatory infusion center, including physician office settings where injectable therapies are provided. Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is an infant or child diagnosed with primary hyperoxaluria type 1 (PH1) or another genetic oxalate overproduction disorder and prescribed lumasiran to reduce hepatic oxalate production. The patient presents to an outpatient infusion clinic, pediatric specialty clinic, or hospital outpatient department for intramuscular or subcutaneous administration per the product monograph (dosing based on weight). Clinical workflow includes verification of prescription and dosing weight, insurance and prior authorization checks, review of allergy and bleeding history, informed consent from the parent or guardian, preparation of the C9074 syringe dose (each unit = 0.5 mg), administration by a licensed clinician (pediatrician, pediatric nurse practitioner, or registered nurse) in a monitored setting, observation for immediate adverse reactions for a short period, documentation of lot number and dosing in the medical record, and submission of the HCPCS Level II code C9074 with appropriate diagnosis and modifier(s) to the payor for reimbursement. Typical sites of service are outpatient infusion centers, pediatric specialty clinics, and hospital outpatient departments. Common clinical considerations include monitoring renal function, oxalate levels, and adherence to the dosing schedule according to the FDA-approved regimen.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 |