J7193 Factor IX (HCPCS) Reimbursement & Benchmarks | OpenPayer

Summary & Overview

HCPCS J7193: Factor IX (non-recombinant) per IU

HCPCS Level II code J7193 denotes purified, non-recombinant Factor IX (antihemophilic factor) billed per international unit. This code captures administration and supply of a critical clotting product used for treatment and prophylaxis in patients with hemophilia B and acquired Factor IX deficiency. Nationally, access and cost for clotting factors are high-priority issues because they affect long-term outcomes, supply logistics, and specialty pharmacy management.

Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of billing context, typical sites of service, and the clinical role of Factor IX products. The publication summarizes common billing modifiers and coding considerations, payer coverage patterns, and benchmarking context where available. It also outlines clinical context relevant to utilization: replacement therapy, perioperative management, and prophylaxis for bleeding prevention.

This summary provides a national-level briefing for revenue cycle managers, specialty pharmacy administrators, and policy analysts on how HCPCS Level II code J7193 is used in practice, what to expect in payer interactions, and where to look for policy or reimbursement updates. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareJ7193HCPCS Level IIFactor IXHemophilia BClotting FactorInfusion TherapySpecialty PharmacyBilling

Billing Code Overview

HCPCS Level II code J7193 represents Factor IX (antihemophilic factor, purified, non-recombinant) billed per international unit (i.u.). This code is used for the billing of purified, non-recombinant Factor IX concentrate used to treat and prevent bleeding in patients with hemophilia B and other Factor IX deficiency states.

Service Type: Replacement therapy / clotting factor administration

Typical Site of Service: Hospital outpatient infusion center, ambulatory infusion center, physician office, or home infusion

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult or pediatric male with Hemophilia B (congenital factor IX deficiency) presenting for factor replacement therapy. Indications include routine prophylaxis to prevent spontaneous bleeding, on-demand treatment for an acute joint or soft-tissue bleed, perioperative management for a scheduled procedure, or treatment of traumatic bleeding. The clinical workflow begins with hematology assessment documenting weight, target factor IX activity, bleeding history, inhibitor status, and the planned indication (prophylaxis, on-demand, or surgical). Pharmacy calculates the required international units (IU) of J7193 based on the patient’s weight and desired rise in factor IX activity. A nurse or infusion specialist prepares and administers the product via intravenous infusion in an outpatient infusion center, hospital infusion unit, emergency department, or ambulatory surgical center. Vital signs and infusion tolerance are monitored during and after administration. Documentation includes indication, total IU dispensed and administered, lot number, reconstitution details, site of service, any applicable modifier(s), and payer information for claims processing. Typical sites of service are outpatient infusion centers, hospital inpatient wards for severe bleeds or perioperative care, emergency departments for acute bleeding, and ambulatory surgical centers for procedures requiring factor coverage.

Coding Specifications

Modifier	Description	When to Use
`JW`

HCPCS J7303: Contraceptive Supply, Hormone-Containing Vaginal Ring

HCPCS-J0706-CAFFEINE-CITRATE-INJECTION-5MG

HCPCS J0706: Injection, Caffeine Citrate, 5 mg

HCPCS-J0283-AMIODARONE-INJECTION-30MG

HCPCS J0283: Amiodarone Hydrochloride Injection, 30 mg

HCPCS-J3486-ZIPRASIDONE-INJECTION-10MG

HCPCS J3486: Injection, Ziprasidone Mesylate, 10 mg

HCPCS-J1748-INFLIXIMAB-DYYB-ZYMFENTRA-10MG-INJECTION

HCPCS Level II J1748: Injection, infliximab-dyyb (Zymfentra), 10 mg

HCPCS-J0741-CABOTEGRAVIR-RILPIVIRINE-INJECTION-2MG-3MG

HCPCS J0741: Injection of Cabotegravir and Rilpivirine, 2mg/3mg

HCPCS-J7644-IPRATROPIUM-INHALATION-SOLUTION-UNIT-DOSE-DME

HCPCS J7644: Ipratropium Bromide Inhalation Solution, Unit-Dose via DME

HCPCS-J3010-FENTANYL-CITRATE-INJECTION-0-1-MG

HCPCS J3010: Injection, Fentanyl Citrate, 0.1 mg

HCPCS-J3472-HYALURONIDASE-OVINE-INJECTION-1000-UNITS

HCPCS Level II J3472: Injection, Hyaluronidase Ovine, Preservative Free

HCPCS-J7212-FACTOR-VIIA-RECOMBINANT-SEVENFACT-1MCG

HCPCS J7212: Factor VIIa (recombinant) (Sevenfact), 1 microgram

Showing 1–10 of 991

Taxonomy Code	Specialty	Notes
`207RH0000X`	Hematology	Primary specialty managing Hemophilia B and prescribing factor IX replacement.
`207RH0003X`	Pediatric Hematology-Oncology	Specialty for pediatric patients with congenital factor IX deficiency.
`261QR0200X`	Infusion Therapy	Nurses and infusion centers administering IV factor replacement.
`208D00000X`	General Surgery	Surgeons who may require perioperative factor IX coverage for procedures.
`2084P0800X`	Emergency Medicine	Emergency physicians involved in acute bleed management and administration of factor IX.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`D66`	Hereditary factor VIII deficiency (Hemophilia A)	Included for differential consideration when clotting factor deficiencies are evaluated; hemophilia A is a different factor deficiency but may be encountered in bleeding workups.
`D67`	Hereditary factor IX deficiency (Hemophilia B)	Primary diagnosis indicating need for `J7193` replacement therapy for congenital factor IX deficiency.
`D68.4`	von Willebrand disease	A bleeding disorder that may require factor concentrates or adjunctive therapies; relevant in differential diagnosis and perioperative planning.
`T80.7XXA`	Hemolytic transfusion reaction, initial encounter	Relevant as a possible adverse transfusion-related event to monitor for when administering blood-derived products.
`R58`	Hemorrhage, not elsewhere classified	Used for acute bleeding events where factor IX replacement is provided to control hemorrhage.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`96413`	Chemotherapy administration, infusion technique; IV infusion for therapy other than cancer drug, up to 1 hour	Used for billing IV infusion services when infusion center bills for administration time of factor IX (depending on payer policies).
`96365`	Intravenous infusion, therapeutic, prophylactic, or diagnostic; initial, up to 1 hour	Alternative administration code often used for therapeutic IV infusions such as factor replacement in outpatient settings.
`36415`	Collection of venous blood by venipuncture	Often performed before or during factor therapy to measure factor IX activity or inhibitor titers.
`85025`	Complete blood count (CBC) with automated differential	Common laboratory test ordered in the peri-infusion period to assess hemoglobin for bleeding.
`85730`	Coagulation time test (e.g., thrombin time) or other coagulation studies	Includes assays used to monitor coagulation status; relevant when assessing response to factor IX.
`99213`	Office or other outpatient visit, established patient, low to moderate complexity	Represents the clinician evaluation visit for dosing, follow-up, or management related to factor IX administration.

OpenPayer