HCPCS J7191: Factor VIII (porcine) per i.u. - OpenPayer

Summary & Overview

HCPCS J7191: Factor VIII (porcine) per i.u.

HCPCS Level II code J7191 designates Factor VIII (antihemophilic factor (porcine)), billed per international unit, and captures porcine-derived factor replacement therapy used to treat hemophilia A. Nationally, accurate coding for high-cost biologics such as J7191 matters for clinical continuity, payer coverage determinations, and appropriate claims processing for complex coagulation care.

Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication summarizes how these payers approach coverage, prior authorization, and coding expectations for porcine Factor VIII products and contrasts them with general biologics policies where relevant.

Readers will learn the clinical context for use of porcine Factor VIII, typical sites of service where dosing is administered, standard billing considerations tied to per i.u. reporting, and which payer categories are commonly involved in reimbursement decisions. The report provides benchmarking and policy-summary content to inform hospital revenue cycle teams, specialty pharmacy managers, and clinicians involved in hemophilia care. Data not available in the input where specific benchmarks, associated ICD-10 diagnoses, and related codes would normally appear.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareJ7191HCPCS Level IIFactor VIIIporcine factorinfusion therapyhematologybiologic drughemophilia Adrug coding

Billing Code Overview

HCPCS Level II code J7191 represents Factor VIII (antihemophilic factor (porcine)), billable per international unit (i.u.). This code describes a derived hemostatic factor replacement therapy product used to treat or prevent bleeding in patients with hemophilia A, specifically formulations sourced from porcine (pig) plasma or recombinant porcine sequences.

Service type: Injectable biologic therapy (factor replacement)

Typical site of service: Hospital outpatient infusion centers, inpatient hospital settings, and specialty infusion clinics

Clinical & Coding Specifications

Clinical Context

A 42-year-old male with acquired hemophilia A secondary to autoimmune disease presents with acute spontaneous soft-tissue bleeding and a factor VIII inhibitor that renders human-derived factor VIII ineffective. The hematology team orders porcine-derived antihemophilic factor to achieve hemostasis. The patient is admitted to an inpatient hematology unit or observed in an infusion center with monitoring for response and adverse events. Pharmacy compounds the billed agent J7191 (Factor VIII, antihemophilic factor (porcine), per I.U.) and documents lot number, units dispensed, and administration details in the medication administration record. Nursing administers the IV infusion per weight-based dosing, monitors vital signs and infusion site, evaluates bleeding control, and records total IUs given. If dosing is adjusted for inadequate response, additional units are documented and billed. Billing captures the exact number of IUs administered using J7191, applies appropriate modifiers for circumstances (for example, QK/QX for physician assistant/assistant-at-surgery when applicable), and links the service to the admitting diagnosis such as hemophilia-related bleeding or inhibitor-associated hemorrhage. Typical sites of service include inpatient hospital units, hospital outpatient infusion centers, emergency departments, and specialty infusion clinics capable of handling high-acuity hemostatic agents.

Coding Specifications

Modifier	Description	When to Use

Related Codes

HCPCS-J1743-IDURSULFASE-INJECTION-1MG

HCPCS J1743: Injection, idursulfase, 1 mg

HCPCS-J3244-TIGECYCLINE-INJECTION-1MG-ACCORD

HCPCS Level II J3244: Tigecycline Injection (Accord), 1 mg

HCPCS-J7647-ISOETHARINE-INHALATION-COMPOUNDED-DME-PER-MG

HCPCS J7647: Isoetharine HCl Inhalation Solution, Compounded, Per mg

HCPCS-J0211-SODIUM-NITRITE-THIOSULFATE-INJECTION-NITHIODOTE

HCPCS J0211: Sodium Nitrite and Sodium Thiosulfate Injection (Nithiodote)

HCPCS-J0638-CANAKINUMAB-INJECTION-1MG

HCPCS Level II J0638: Canakinumab Injection, 1 mg

HCPCS-J0725-CHORIONIC-GONADOTROPIN-INJECTION-1000-USP-UNITS

HCPCS J0725: Injection, Chorionic Gonadotropin, per 1,000 USP Units

HCPCS-J2562-PLERIXAFOR-INJECTION-1MG

HCPCS Level II J2562: Plerixafor Injection, 1 mg

HCPCS-J2267-MIRIKIZUMAB-INJECTION-1MG

HCPCS J2267: Injection, mirikizumab-mrkz, 1 mg

HCPCS-J7527-EVEROLIMUS-ORAL-025-MG

HCPCS J7527: Everolimus, Oral, 0.25 mg

HCPCS-J7628-BITOLTEROL-INHALATION-COMPOUNDED-DME

HCPCS J7628: Bitolterol Mesylate Inhalation Solution, Compounded

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`00`	No modifier	Use when no other modifier applies to the claim for `J7191`.
`22`	Increased procedural services	Use when unusually high dosing or complexity requires additional documentation and payer approval for higher payment.
`52`	Reduced services	Use if a planned portion of therapy was not completed (partial dosing withheld).
`53`	Discontinued procedure	Use when therapy was started but discontinued due to patient instability or adverse reaction.
`62`	Two surgeons	Use when two surgeons of different specialties are required for a procedure associated with administration (rare for infusion but applicable if surgical hemostasis performed concurrently).
`80`	Assistant surgeon	Use when an assistant surgeon is billed in conjunction with a surgical procedure related to bleeding control.
`82`	Assistant surgeon (when qualified resident unavailable)	Use when a qualified resident is unavailable and an assistant surgeon assists with operative hemorrhage control.
`AS`	Physician assistant or nurse practitioner	Use to indicate services furnished by a physician assistant or nurse practitioner when permitted by payer rules.
`QX`	Service furnished by a CRNA with physician present (modifier for Medicare when using Q codes)	Use when a certified registered nurse anesthetist provides anesthesia-related services during administration for a procedure requiring anesthesia.
`QY`	Service furnished by a physician assistant under direct supervision	Use when a PA provides the infusion service under direct supervision and payer requires `QY`.
`CQ`	Service furnished by a dental resident in a CMS-approved program	Use only when applicable in dental residency settings (rare for `J7191`).
`FX`	No standard CMS definition — payer-specific	Use according to payer policy when they recognize `FX` for specific situations.
`FY`	No standard CMS definition — payer-specific	Use according to payer policy when they recognize `FY` for specific situations.
`TG`	Service furnished under a teaching physician's presence	Use when a teaching physician is present and billing requirements mandate an educational modifier.

Taxonomy Code	Specialty	Notes
`207RH0000X`	Hematology	Primary specialty managing bleeding disorders and prescribing porcine factor VIII.
`2080P0207X`	Hospitalist	Manages inpatient care, coordinates dosing and monitoring of factor therapy.
`363L00000X`	Emergency Medicine	Initial stabilization and ordering of hemostatic therapy for acute bleeding presentations.
`208000000X`	Internal Medicine	Manages chronic comorbidities and coordinates outpatient infusion when needed.
`174400000X`	Pharmacy (Inpatient/Infusion)	Hospital/institutional pharmacists verify dosing, document lot numbers, and prepare infusion.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`D68.32`	Acquired hemophilia	Primary indication for porcine-derived factor VIII when inhibitors to human factor VIII are present.
`D66`	Hereditary factor VIII deficiency (Hemophilia A)	Indicates hemophilia A; porcine factor VIII may be used in inhibitor-positive patients.
`D68.4`	Von Willebrand disease	Severe forms with refractory bleeding occasionally managed with alternate factor therapies.
`T80.8XXA`	Other complications following infusion, initial encounter	Captures infusion-related adverse events that may occur with `J7191`.
`R58`	Hemorrhage, not elsewhere classified	Represents acute bleeding episodes requiring hemostatic therapy such as `J7191`.
`I97.1`	Postprocedural hemorrhage and hematoma	Bleeding after procedures where factor VIII replacement may be required.
`O74.8`	Other complications of anesthesia during labor and delivery	When postpartum hemorrhage with inhibitors necessitates specialized hemostatic therapy.
`Z79.01`	Long term (current) use of antithrombotics/antiplatelets	Relevant as concomitant medications that affect bleeding risk and factor dosing.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`36415`	Collection of venous blood by venipuncture	Performed prior to `J7191` administration for baseline labs (CBC, coagulation studies).
`85025`	Blood count; complete (CBC), automated and automated differential WBC count	Used before and after factor administration to monitor for bleeding impact and transfusion needs.
`85384`	Coagulation factor assays (e.g., factor VIII activity)	Measures factor VIII activity to guide dosing and assess response to porcine factor VIII.
`99223`	Initial hospital care, typically 70 minutes or more	Admission evaluation for a patient with major hemorrhage who will receive `J7191`.
`96365`	Intravenous infusion, initial, up to 1 hour	Billed for the infusion administration time when `J7191` is administered in an infusion setting.
`96371`	Therapeutic, prophylactic, or diagnostic injection (intramuscular or subcutaneous)	Occasionally used when alternative routes or adjunctive injectable therapies are administered alongside `J7191`.