Summary & Overview
HCPCS J7165: Prothrombin Complex Concentrate (Factor IX) Injection
HCPCS Level II code J7165 represents administration of prothrombin complex concentrate (human-lans) billed per international unit of factor IX activity. This injectable biologic is used to provide vitamin K–dependent clotting factors and to manage bleeding disorders or coagulopathy in acute care settings. Nationally, accurate coding of high-cost clotting factor products affects coverage decisions, hospital billing, and pharmacy/therapeutics oversight.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical role, typical sites of service, and the payer landscape relevant to coverage and billing. The publication outlines benchmarks for billing and utilization, recent policy or reimbursement updates where available, and clinical context for appropriate use of prothrombin complex concentrates. Where specific data points are not provided in the input, the publication notes that those details are unavailable and focuses on actionable coding, service-line alignment, and payer considerations for national audiences.
Billing Code Overview
HCPCS Level II code J7165 describes an injection of prothrombin complex concentrate, human-lans, billed per international unit of factor IX activity. This product is a plasma-derived concentrate used to replace vitamin K–dependent clotting factors, primarily administered to treat or manage bleeding in patients with factor IX deficiency or to reverse coagulopathy when indicated.
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Service Type: Injectable biologic / coagulation factor replacement
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Typical Site of Service: Hospital inpatient, hospital outpatient infusion center, or other acute care settings where intravenous factor replacement is administered
Clinical & Coding Specifications
Clinical Context
A 58-year-old male with chronic atrial fibrillation on warfarin presents to the emergency department with acute major gastrointestinal bleeding and an elevated INR of 6.2. After hemodynamic stabilization, the clinical team determines urgent reversal of vitamin K–dependent coagulation factors is required. The patient receives an intravenous infusion of prothrombin complex concentrate to rapidly restore factor IX activity and correct coagulopathy. The typical workflow includes urgent physician assessment, order entry for J7165 with calculated international units based on factor IX activity, verification by pharmacy, preparation and infusion in the ED or inpatient setting, post-infusion laboratory monitoring of coagulation parameters (INR, PT), and documentation of dose, lot numbers, and reason for reversal in the medical record.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier — default billing | Use when no specific modifier applies to the administration of J7165. |
| 22 | Increased procedural services | Use when complexity or time for preparation/administration substantially exceeds usual service (rare for vial-based infusion but applicable if extraordinary steps required).