J7192 Factor VIII (HCPCS) Reimbursement & Benchmarks | OpenPayer

Summary & Overview

HCPCS J7192: Factor VIII (recombinant) per International Unit

HCPCS Level II code J7192 denotes recombinant Factor VIII (antihemophilic factor) billed per international unit when no more specific product code is used. Factor VIII products are essential biologic therapies for patients with hemophilia A and certain bleeding disorders; accurate coding affects clinical documentation, inventory management, and payer reimbursement for high-cost biologic infusions. Nationally, consistent use of a per-i.u. code like J7192 matters for cost tracking and claims processing when brand- or formulation-specific codes are not reported.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find benchmarks and context on billing practices for recombinant Factor VIII when per-i.u. reporting is employed, an overview of payer coverage considerations, and clinical context for the service line. The publication outlines typical sites of service for administration, common billing modifiers used in practice (data provided separately), and areas where policy updates or payer-specific rules may affect claims. Data not available in the input is noted where relevant. This summary is written for a national audience seeking clarity on coding, billing pathways, and the administrative implications of using HCPCS Level II code J7192.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareJ7192HCPCS Level IIFactor VIIIhemophilia Arecombinant biologicinfusion therapydrug per i.u.medical billingoutpatient infusion

Billing Code Overview

HCPCS Level II code J7192 represents Factor VIII (antihemophilic factor, recombinant) billed per international unit (i.u.), not otherwise specified. This code describes recombinant factor VIII product dosing measured in international units and is used when a specific branded or formulation code is not reported.

Service type: Therapeutic biologic replacement therapy for hemophilia A and related bleeding disorders
Typical site of service: Infusion or injection in inpatient hospital, outpatient infusion center, hospital outpatient department, or ambulatory infusion setting

Clinical & Coding Specifications

Clinical Context

A 28-year-old male with severe hemophilia A (congenital Factor VIII deficiency) presents to an outpatient infusion center for routine prophylactic replacement therapy with recombinant antihemophilic factor. The patient has a port-a-cath in place and arrives with recent factor usage documented in the electronic medical record. Pharmacy prepares recombinant Factor VIII dosed in international units (I.U.) per weight; billing is submitted using J7192 to report Factor VIII (antihemophilic factor, recombinant) per I.U., not otherwise specified. The infusion nurse verifies patient identity, vital signs, and inhibitor history; obtains baseline labs if clinically indicated; administers the intravenous infusion; monitors for allergic reaction or inhibitor-related reduced efficacy; and documents lot numbers, total units administered, and the route of administration.

Typical workflow steps:

Referral/order placed by a hematologist with dosage in I.U. and administration frequency.
Pharmacy compounds/dispenses recombinant Factor VIII; records NDC and lot information.
Infusion nurse performs pre-infusion assessment, confirms consent, and administers medication.
Post-infusion monitoring and documentation including units infused, patient response, and any adverse events.
Billing staff submits claim using J7192 with applicable modifiers and links to the treating diagnosis code(s).

Coding Specifications

Modifier selection focuses on clinical and billing scenarios common for recombinant Factor VIII administration. The table lists the most relevant 10–15 modifiers from the supplied set.

HCPCS J0884: Injection, Argatroban 1 mg (ESRD on Dialysis)

HCPCS-J1945-LEPIRUDIN-INJECTION-50MG

HCPCS J1945: Injection, lepirudin, 50 mg

HCPCS-J0210-METHYLDOPATE-INJECTION-250MG

HCPCS J0210: Injection, Methyldopate HCl, up to 250 mg

HCPCS-J2995-STREPTOKINASE-INJECTION-250000-IU

HCPCS J2995: Injection, Streptokinase, per 250,000 IU

HCPCS-J3385-VELAGLUCERASE-ALFA-INJECTION-100-UNIT

HCPCS J3385: Injection, velaglucerase alfa, 100 units

HCPCS-J3530-NASAL-VACCINE-INHALATION

HCPCS J3530: Nasal Vaccine Inhalation

HCPCS-J1439-FERRIC-CARBOXYMALTOSE-INJECTION-1MG

HCPCS J1439: Ferric Carboxymaltose Injection, 1 mg

HCPCS-J0894-DECITABINE-INJECTION-1MG

HCPCS J0894: Decitabine Injection, 1 mg

HCPCS-J0578-BUPRENORPHINE-EXTENDED-RELEASE-BRIXADI-7-28-DAYS

HCPCS Level II J0578: Buprenorphine Extended-Release Injection, 7–28 Days

HCPCS-J2471-PANTOPRAZOLE-HIKMA-40MG-INJECTION

HCPCS Level II J2471: Pantoprazole (Hikma) Injection, 40 mg

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Modifier	Description	When to Use
`JW`	Drug amount discarded/not administered (per CMS)	Use when some drug waste is discarded and payor allows reporting of discarded portion for single-use vials.
`JZ`	Zero drug amount discarded	Use when no drug waste was discarded and all supplied units were administered.
`LT`	Left side	Use when laterality is required for an associated procedure (for example a vascular access site on the left).
`62`	Two surgeons	Use when two surgeons from different specialties are required during a concurrent procedure related to access placement or surgical management of bleeding.
`76`	Repeat procedure by same physician	Use when the same physician performs a repeated, separate administration encounter the same day.
`78`	Unplanned return to OR by same physician following initial procedure	Use when an infusion-related surgical intervention or access complication requires return to the operating room.
`11`	Administrative or procedural modifier (state-specific professional component)	Use per payor rules to indicate physician supervision/oversight when required.
`22`	Increased procedural services	Use when administration required substantially greater effort or resources (documented) — payors review for medical necessity.
`62`	(duplicate entry removed)	(see above)
`52`	Reduced services	Use when the infusion or service was partially reduced or not completed as planned.
`53`	Discontinued procedure	Use when administration was started but discontinued due to patient reaction or other clinical issues.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for Medicare Part B	Use when an NP/PA provides services that are reported under their identifier per Medicare rules.
`FY`	Left intact catheter/device (payor-specific)	Use if an implantable device remains in place following service (use per payor rules).
`QX`	CRNA service with medical direction by physician	Use when a certified registered nurse anesthetist provides anesthesia services under physician direction for procedures requiring anesthesia during complex infusions or access placement.

Taxonomy Code	Specialty	Notes
207RH0000X	Hematology	Hematologists prescribe and manage factor replacement therapy and inhibitor surveillance.
363LF0000X	Pharmacy	Infusion center pharmacists prepare and verify recombinant Factor VIII dosing, NDCs, and lot numbers.
353L00000X	Nurse Practitioner	NPs manage outpatient infusion clinics, perform assessments, and may supervise infusions.
364S00000X	Registered Nurse	Infusion RNs administer the product, monitor patients, and document units infused.
208D00000X	Pediatrics (when applicable)	Pediatric hematologists manage children with hemophilia receiving weight‑based dosing.

Related Diagnoses

No ICD-10 diagnosis codes were provided in the input. The following are the most commonly associated diagnosis codes for Factor VIII replacement based on standard clinical practice.

ICD-10 Code	Description	Clinical Relevance
`D66`	Hereditary factor VIII deficiency	Primary diagnosis for patients with hemophilia A requiring recombinant Factor VIII replacement.
`D68.4`	Acquired coagulation factor deficiency	Used when a patient has acquired factor VIII deficiency requiring replacement therapy.
`T80.52XA`	Adverse effect of other blood products, initial encounter	Relevant if the patient has an acute infusion reaction to factor concentrate.
`T80.59XA`	Other complications of infusion, initial encounter	Used for other infusion-related complications requiring treatment or observation.
`I85.0`	Esophageal varices with bleeding	Possible bleeding indication where factor replacement may be used in patients with coagulopathy; clinical context determines use.

Related CPT Codes

When CPT codes were not provided, commonly associated CPT codes for procedures performed alongside or related to recombinant Factor VIII infusion are listed below.

CPT Code	Description	Relationship to This Procedure
`96365`	Intravenous infusion, initial, up to 1 hour	Used to report the initial IV infusion administration service when recombinant Factor VIII is administered in an infusion center.
`96366`	Intravenous infusion, each additional hour	Used for prolonged infusion time beyond the initial hour when monitoring or extended observation is required.
`36415`	Collection of venous blood by venipuncture	Used for pre- or post-infusion laboratory draws such as factor levels or inhibitor screens.
`36000`	Introduction of needle/catheter into vein for injection/infusion	Used when peripheral IV access is established for administration of Factor VIII.
`36561`	Insertion of tunneled central venous catheter, without subcutaneous port or pump	Used when long-term central access is placed for recurrent home or clinic infusions in patients with difficult peripheral access.

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