HCPCS Level II C9162: Injection, avacincaptad pegol, 0.1 mg - OpenPayer

Summary & Overview

HCPCS Level II C9162: Injection, avacincaptad pegol, 0.1 mg

HCPCS Level II code C9162 denotes the injection formulation of avacincaptad pegol at 0.1 mg. This code identifies the specific drug product and dosage unit used primarily in ophthalmology for intravitreal administration. Accurate coding with C9162 is important for claims processing, pharmacy-administration workflows, and national monitoring of specialty ophthalmic biologic use.

Key payers referenced in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise national overview of the code’s clinical context, common sites of service, and the payer landscape relevant to coverage and reimbursement. The publication summarizes benchmarks where available, notes typical claim line composition for an injectable ophthalmic agent, and highlights areas for operational attention such as unitization and billing alignment with drug vial sizes.

This summary is written for a national audience and covers clinical usage context, payer coverage patterns, and practical billing considerations tied to C9162. Data not available in the input will be identified explicitly in detailed sections.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareC9162HCPCS Level IIavacincaptad pegolophthalmologyinjectable medicationintravitreal injectiondrug administrationoutpatient services

Billing Code Overview

HCPCS Level II code C9162 describes Injection, avacincaptad pegol, 0.1 mg. This code represents administration of a specific ophthalmologic biologic agent formulated in 0.1 mg increments. Service type: injectable medication administration. Typical site of service: outpatient ophthalmology clinic or ambulatory infusion/ocular injection suite.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult with neovascular (wet) age-related macular degeneration or other retinal neovascular disease presenting with decreased central vision, metamorphopsia, or new central scotoma. Ophthalmology clinic evaluation includes visual acuity testing, slit-lamp biomicroscopy, dilated fundus exam, optical coherence tomography (OCT) and, when indicated, fluorescein angiography. After diagnosis and discussion of risks and benefits, the retina specialist prepares intravitreal injection of avacincaptad pegol (HCPCS C9162), dosed per vial with billing per 0.1 mg unit. The typical site of service is an outpatient ophthalmology clinic, ambulatory surgery center, or hospital outpatient department where sterile intravitreal injection procedures are performed.

The clinical workflow: pre-procedure consent and allergy review; topical anesthesia and antisepsis with povidone-iodine; optional subconjunctival or topical anesthetic; eyelid speculum placement; intravitreal injection of avacincaptad pegol under sterile technique; post-injection intraocular pressure check and retina assessment; written aftercare instructions and scheduled follow-up within 1–4 weeks for assessment and possible repeat dosing. Billing uses HCPCS C9162 per 0.1 mg increment with appropriate facility and payer modifiers as indicated.

Coding Specifications

Modifier	Description

HCPCS C1725: Transluminal Angioplasty Catheter, Non-Laser

HCPCS-C9362-POROUS-COLLAGEN-MATRIX-BONE-VOID-FILLER-0-5CC

HCPCS C9362: Porous Collagen Matrix Bone Void Filler, per 0.5 cc

HCPCS-C1780-INTRAOCULAR-LENS-NEW-TECHNOLOGY

HCPCS C1780: Intraocular Lens, New Technology

HCPCS-C9167-ADAMTS13-RECOMBINANT-INJECTION-10-IU

HCPCS Level II C9167: Injection, recombinant ADAMTS13, 10 IU

HCPCS-C9080-MELPHALAN-FLUFENAMIDE-INJECTION-1MG

HCPCS Level II C9080: Injection, melphalan flufenamide hydrochloride, 1 mg

HCPCS-C9602-PERCUTANEOUS-CORONARY-ATHERECTOMY-DRUG-ELUTING-STENT

HCPCS C9602: Percutaneous Coronary Atherectomy with Drug‑Eluting Stent

HCPCS-C7543-ERCP-SPHINCTEROTOMY-PAPILLOTOMY-CANNULATION-VISUALIZATION

HCPCS C7543: ERCP with Sphincterotomy/Papillotomy and Duct Cannulation

HCPCS-C1752-SHORT-TERM-HEMODIALYSIS-PERITONEAL-CATHETER

HCPCS C1752: Short-Term Hemodialysis/Peritoneal Catheter

HCPCS-C2626-IMPLANTABLE-TEMPORARY-NON-PROGRAMMABLE-INFUSION-PUMP

HCPCS C2626: Implantable Temporary Non-Programmable Infusion Pump

HCPCS-C9140-FACTOR-VIII-AFSTYLA-INJECTION-1-IU

HCPCS C9140: Injection, Factor VIII (Afstyla), 1 I.U.

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`22`	Increased procedural services	Use when work required is substantially greater than typically required for the intravitreal injection (e.g., complex sedation, multiple attempts, dense vitreous hemorrhage management).
`23`	Unusual anesthesia services	Use if general anesthesia or monitored anesthesia care is required for the injection when unusual circumstances prevent local/topical anesthesia.
`52`	Reduced services	Use if the full planned dose or service was partially reduced or not completed (e.g., incomplete injection due to adverse event).
`53`	Discontinued procedure	Use if the injection procedure was started but terminated due to unforeseen complication prior to administration of medication.
`54`	Surgical care only	Use when billing only the surgical component and pre/post care billed separately by another provider.
`55`	Postoperative management only	Use when another provider bills the injection/surgery and the reporting provider bills only post-op care.
`56`	Preoperative management only	Use when reporting pre-op management when another provider performs the injection.
`62`	Two surgeons	Use when two surgeons of different specialties or equal standing are required and both actively participate in the intravitreal injection procedure.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist service performed in part by the PA/NP/CNS	Use when a qualified non-physician practitioner performs part of the professional services under appropriate state law and payer rules.
`CQ`	Service furnished by a physical therapist in a home health setting	Generally not applicable to intravitreal injection; include only if a qualifying therapy service occurs in conjunction with the injection under payer rules.
`QK`	Medical direction of two, three, or four assistants	Use when the physician directs multiple assistants involved in perioperative support for the procedure and payer accepts assistant modifiers.
`QX`	CRNA service with qualified physician present	Use for anesthesia services when a certified registered nurse anesthetist provides anesthesia and a physician is present as required by payer rules.
`QY`	Medical direction of one anesthetist	Use when physician provides direct medical direction of one anesthetist for anesthesia related to the injection.
`SH`	Speech-language pathology services — assistant	Not typically applicable; include only if an assisting clinician with this modifier provides qualifying services in the same encounter per payer policy.

Taxonomy Code	Specialty	Notes
`207W00000X`	Ophthalmology	Retina specialists (vitreoretinal surgeons) most commonly perform intravitreal injections of avacincaptad pegol.
`207RC0000X`	Retina Specialist	Subspecialty within ophthalmology focused on medical and surgical retinal disease; primary billing providers for this agent.
`363A00000X`	Certified Registered Nurse Anesthetist	In cases requiring anesthesia beyond topical agents, CRNAs provide monitored anesthesia care.
`363L00000X`	Registered Nurse	Clinic RNs assist with injection preparation, topical anesthesia, and post-injection monitoring.
`2084P0800X`	Physician Assistant	PAs in ophthalmology clinics may perform or assist with injections per state scope and payer policy.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`H35.32`	Exudative age-related macular degeneration	Primary indication for intravitreal anti-VEGF or complement-targeted therapies like avacincaptad pegol in neovascular AMD.
`H35.31`	Nonexudative age-related macular degeneration	Relevant for monitoring disease progression; conversion to exudative AMD may prompt use of intravitreal therapy.
`H35.81`	Other retinal disorders	Broad category that can include degenerative or inflammatory conditions treated with intravitreal injections depending on agent and pathology.
`H35.60`	Macular degeneration, unspecified	Used when documentation does not specify exudative vs nonexudative at time of billing; may require clarification.
`H35.89`	Other specified retinal disorders	Covers less common retinal pathologies where intravitreal pharmacotherapy is considered.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`67028`	Intravitreal injection of a pharmacologic agent (separate procedure)	Directly corresponds to the intravitreal administration technique; commonly reported by the injecting physician alongside HCPCS `C9162` when payer allows separate CPT reporting for the injection procedure.
`67036`	Vitrectomy, pars plana, with removal of vitreous (including diagnostic vitrectomy)	Performed when vitreous opacities or hemorrhage preclude safe intravitreal injection or when concurrent surgical intervention is required.
`92250`	Fundus photography with interpretation and report	Often performed before or after injection to document retinal status and treatment response.
`92134`	Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report; unilateral or bilateral	Optical coherence tomography (OCT) is commonly used for diagnosis and monitoring response to intravitreal avacincaptad pegol.
`92235`	Fluorescein angiography with interpretation and report	Performed when vascular leakage or neovascularization needs angiographic evaluation to guide treatment decisions.

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