Summary & Overview
HCPCS G9035: Oseltamivir Phosphate 75 mg, Oral, Brand
HCPCS Level II code G9035 denotes the brand formulation of oseltamivir phosphate, oral, per 75 mg, submitted for use in a Medicare-approved demonstration project. The code is relevant nationally as it tracks dispensing of a prescription antiviral under specific demonstration program rules, supporting program monitoring, reimbursement alignment, and supply-chain management for antiviral treatments.
Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on clinical use of oseltamivir in outpatient settings, the service type and typical sites of dispensing, and what to expect from billing and program reporting when a medication is linked to a Medicare demonstration. The publication outlines benchmark considerations, payer coverage patterns, program-specific billing expectations, and clinical context for antiviral dispensing under demonstration projects. Data not available in the input will be noted where applicable.
Billing Code Overview
HCPCS Level II code G9035 represents Oseltamivir phosphate, oral, brand, per 75 mg, specifically noted for use in a Medicare-approved demonstration project. This code describes a pharmacy-dispensed oral antiviral medication formulation of oseltamivir at the 75 mg dose.
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Service type: Outpatient oral antiviral medication dispensed under a demonstration project
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Typical site of service: Retail or outpatient pharmacy; dispensing may occur in clinic settings participating in the Medicare-approved demonstration project
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Clinical & Coding Specifications
Clinical Context
A typical patient is an adult presenting to a primary care clinic or public health demonstration site during influenza season with acute onset of fever, cough, myalgias, or upper respiratory symptoms within 48 hours of symptom onset. The site is participating in a Medicare-approved demonstration project that provides branded antiviral medication. The clinician confirms influenza infection clinically or with a rapid influenza diagnostic test, documents medical necessity, and prescribes/dispenses G9035 (oseltamivir phosphate, oral, brand, per 75 mg) to the patient. The workflow includes clinical assessment, point-of-care testing as indicated, medication reconciliation, counseling on dosing and side effects, and documentation of participation in the demonstration project in the medical record and claim form. Typical sites of service include outpatient primary care clinics, urgent care centers, community health centers, and public health demonstration clinics administering medications under the Medicare demonstration protocol.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure | Use when a separate E/M is performed and documented on the day the medication is prescribed or dispensed |