C9138 Recombinant Factor VIII (HCPCS) Reimbursement | OpenPayer

Summary & Overview

HCPCS C9138: Recombinant Factor VIII (Nuwiq) Injection, 1 IU

HCPCS Level II code C9138 designates administration of recombinant factor VIII (Nuwiq) dosed per 1 international unit. This biologic injection is a core therapy for individuals with hemophilia A and is clinically significant due to high unit-based dosing, specialized handling, and substantial cost implications for payers and health systems. Nationally, accurate coding for factor concentrates is critical for claims accuracy, utilization monitoring, and specialty pharmacy workflows. Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the clinical context for C9138, typical sites of service where the injection is administered, and what to expect in coverage and billing practice at a national level. The publication outlines benchmarks for unit-based billing, common coding considerations for infusion and outpatient settings, and policy-relevant updates affecting biologic clotting-factor claims. The content also summarizes payer coverage patterns and reimbursement themes important to providers, billing professionals, and policy analysts working with specialty therapeutics in hematology.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareC9138HCPCS Level IIrecombinant factor VIIIhemophilia Ainfusionbiologic therapyspecialty pharmacyoutpatient infusion

Billing Code Overview

HCPCS Level II code C9138 describes an injection of factor VIII (antihemophilic factor, recombinant) (Nuwiq) dosed per 1 international unit (i.u.). The code represents a biologic replacement therapy used to treat hemophilia A by providing recombinant factor VIII to correct clotting deficiency.

Service type: Therapeutic infusion/injection of clotting factor

Typical site of service: Hospital outpatient infusion center, infusion clinic, or physician office

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 28-year-old male with severe hemophilia A presents to a hemophilia treatment center for routine prophylactic factor replacement and for treatment of an acute joint bleed in the right knee following minor trauma. The patient receives a calculated dose of recombinant antihemophilic factor (Nuwiq) administered by intravenous infusion in an outpatient infusion suite. Nursing documents weight, dose in international units, lot number, expiration, infusion start and stop times, pre- and post-infusion vital signs, and any infusion-related reactions. The clinical workflow includes provider order (dose in I.U.), medication verification by pharmacy, preparation and labeling of the infusion product, bedside verification using two identifiers, IV access or venous port assessment, administration of the factor, and post-infusion discharge instructions. Billing is performed using HCPCS Level II code C9138 reported per international unit with the total units documented on the claim. Typical sites of service include hospital outpatient infusion centers, specialized hemophilia treatment centers, ambulatory infusion clinics, and occasionally skilled nursing facilities for home infusion support.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional Component	Rarely used for drug administration; used only if reporting a separately payable professional component for associated services documented separately.

HCPCS C7523: Coronary Catheterization with IVUS/OCT

HCPCS-C9301-CD19-CAR-T-CELL-THERAPY-OBECABTAGENE-AUTOLEUCEL

HCPCS C9301: Obecabtagene Autoleucel, CD19 CAR T-cell Therapy

HCPCS-C9776-INTRAOPERATIVE-NEAR-INFRARED-BILE-DUCT-IMAGING-ICG

HCPCS C9776: Intraoperative Near-Infrared Bile Duct Imaging with ICG

HCPCS-C1982-PRESSURE-GENERATING-CATHETER-ONE-WAY-VALVE

HCPCS C1982: Pressure-Generating Catheter (One-Way Valve)

HCPCS-C8006-PLEURAL-PERITONEAL-SHUNT-INSERTION-INTERCOSTAL-PUMP

HCPCS C8006: Pleural-Peritoneal Shunt Insertion with Intercostal Pump Chamber

HCPCS-C8920-MRA-PELVIS-WITHOUT-THEN-WITH-CONTRAST

HCPCS C8920: Magnetic Resonance Angiography Pelvis Without Then With Contrast

HCPCS-C9039-PLAZOMICIN-INJECTION-5MG

HCPCS C9039: Plazomicin Injection, 5 mg

HCPCS-C9479-CIPROFLOXACIN-OTIC-INSTILLATION-6MG

HCPCS C9479: Ciprofloxacin Otic Instillation, 6 mg

HCPCS-C2627-SUPRAPUBIC-CYSTOSCOPIC-CATHETER

HCPCS C2627: Catheter, Suprapubic/Cystoscopic

HCPCS-C9469-TRIAMCINOLONE-EXTENDED-RELEASE-INJECTION-1MG

HCPCS C9469: Triamcinolone Acetonide Extended‑Release Injection, 1 mg

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Taxonomy Code	Specialty	Notes
`207RH0000X`	Hematology	Hematologists manage hemophilia diagnosis, dosing decisions, and long-term care.
`163WL0500X`	Pediatric Hematology-Oncology	Pediatric specialists manage dosing and administration for children with hemophilia A.
`333600000X`	Clinical Nurse Specialist	Infusion-trained advanced practice nurses who administer and oversee factor infusions.
`364S00000X`	Registered Nurse	Infusion nurses performing medication preparation, administration, and documentation.
`207L00000X`	Internal Medicine	Internists involved in adult hemophilia management in some centers.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`D66`	Hereditary factor VIII deficiency	Primary diagnosis for hemophilia A; direct indication for recombinant factor VIII replacement therapy.
`D68.4`	von Willebrand disease	Some patients with severe von Willebrand disease may receive factor VIII-containing concentrates; clinical relevance depends on subtype and product indication.
`M25.561`	Pain in right knee	Symptom code that may accompany an acute hemarthrosis treated with factor VIII infusion.
`M25.562`	Pain in left knee	Symptom code for contralateral joint pain related to bleeding episodes.
`T81.0XXA`	Hemorrhage and hematoma complicating a procedure, initial encounter	Used if bleeding complication arises related to a procedure requiring factor replacement.
`Z79.01`	Long term (current) use of anticoagulants	Relevant for medication reconciliation and assessing bleeding risk when managing factor replacement, though anticoagulant use is typically avoided in hemophilia.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`96365`	Intravenous infusion, initial, up to 1 hour	Used when the infusion of factor VIII is initiated and the infusion duration is up to one hour for an outpatient infusion encounter.
`96366`	Intravenous infusion, each additional hour	Used when infusion time extends beyond the initial hour and additional hourly reporting is applicable.
`36415`	Collection of venous blood by venipuncture	Performed prior to infusion for baseline labs such as factor levels, CBC, or inhibitor testing.
`96374`	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); Intravenous push, single or initial substance/drug	Occasionally used for short IV push administrations if the factor is administered as a bolus per prescriber orders and payer allows.
`96372`	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular	Used when supportive injections (e.g., hemostatic adjuvants or other subcutaneous medications) are administered in conjunction with the factor infusion.

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