Summary & Overview
HCPCS G9036: Rimantadine oral, brand, 100 mg
HCPCS Level II code G9036 designates branded rimantadine hydrochloride oral tablets at 100 mg strength for use specifically within Medicare-approved demonstration projects. Nationally, this code matters for tracking access, coverage, and reporting of antiviral agents provided under demonstration initiatives that test new care or payment models. It also establishes a standardized identifier for billing and monitoring dispensed medication related to these projects.
Key payers referenced include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication outlines payer coverage considerations, where available, and highlights how this HCPCS Level II code is used in pharmacy and demonstration project settings.
Readers will learn the clinical context of G9036, the typical service and site of service, and which major payers are included in the scope of analysis. Where input data is missing, the document notes the absence: details such as common modifiers, associated taxonomies, ICD-10 diagnoses, related codes, and specific payer policy language are listed as not available in the input. The focus is national in scope and intended to support billing, policy navigation, and operational planning for entities participating in Medicare-approved demonstration projects involving antiviral dispensing.
Billing Code Overview
HCPCS Level II code G9036 represents Rimantadine hydrochloride, oral, brand, per 100 mg (for use in a Medicare-approved demonstration project). The code denotes a branded oral antiviral medication formulation intended for specialized use within Medicare-approved demonstration projects.
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Service type: Pharmacy-dispensed oral antiviral medication intended for administration as part of a demonstration project.
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Typical site of service: Outpatient pharmacy or other outpatient dispensing site supporting Medicare demonstration project participants.
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A Medicare beneficiary enrolled in a CDC or Medicare-approved antiviral demonstration project presents to a participating clinic during influenza season for outpatient management and prophylaxis. The patient is an older adult with documented exposure to influenza A or with early symptoms consistent with influenza A where rimantadine hydrochloride is considered appropriate by study protocols. The clinical workflow includes verification of patient enrollment in the demonstration project, review of eligibility criteria, informed consent per study requirements, medication counseling, and documentation of administration or dispensing of G9036 for a 100 mg oral brand formulation. The provider documents the indication, review of contraindications (including pregnancy and seizure disorders), concurrent medications, and any adverse reactions. Pharmacy fills the prescription or provides the drug on-site, and the encounter note and demonstration project forms are completed for Medicare reporting and billing purposes.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
24 | Unrelated Evaluation and Management service by the same physician during a postoperative period | Use when an unrelated E/M visit occurs during a demonstration project follow-up period if applicable to provider billing rules. |