Summary & Overview
HCPCS J7197: Antithrombin III (human), per international unit
HCPCS Level II code J7197 identifies antithrombin III (human) measured and billed per international unit. This biologic product is clinically important for managing patients with antithrombin deficiency or those experiencing consumptive coagulopathy in high‑risk procedures, and it carries national relevance due to its use in acute inpatient care and specialized infusion settings. Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare and Medicare. Readers will find a concise overview of clinical indications and service context, payer coverage scope, common billing modifiers, and benchmarking considerations for utilization and reimbursement where available. The publication also outlines coding nuances for billing antithrombin concentrate per unit and highlights where input data were unavailable. The goal is to provide clinicians, billing staff, and policy analysts with a clear reference for the code's clinical role, typical sites of service, and the payer landscape to inform documentation and claims submission practices.
Billing Code Overview
HCPCS Level II code J7197 represents Antithrombin III (human), per international unit (i.u.), a plasma‑derived coagulation factor concentrate used to restore antithrombin activity in patients with deficiency or during certain clinical situations that consume antithrombin (for example, during cardiopulmonary bypass or severe sepsis). The service type is a biologic drug infusion/administration and supply. The typical site of service is an inpatient hospital setting or an outpatient infusion center where parenteral therapies and blood‑product–derived biologics are administered.
Clinical & Coding Specifications
Clinical Context
A 45-year-old patient with severe hereditary antithrombin III deficiency presents with recurrent venous thromboembolism despite therapeutic anticoagulation, or with acute disseminated intravascular coagulation (DIC) in the setting of sepsis and documented low antithrombin levels. The treating hematologist orders replacement therapy with antithrombin III concentrate to restore physiologic antithrombin activity prior to or during high-risk procedures (for example, major surgery or invasive catheter placement) or to reverse heparin resistance during therapeutic anticoagulation. The product billed is J7197 (antithrombin III, human, per I.U.).
Workflow:
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Initial evaluation and documentation by a hematologist or intensivist including diagnosis, baseline antithrombin activity level, indication for replacement, dosage calculation (IU/kg or target activity), and informed consent if required.
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Pharmacy preparation and verification of human antithrombin concentrate dose based on weight and desired activity level.
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Administration in an inpatient or outpatient infusion setting by nursing staff with monitoring of vital signs and coagulation parameters. Typical sites of service include inpatient hospital (acute care), outpatient infusion center, and specialized hematology clinics.
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Post-infusion monitoring of antithrombin activity and adjustment of subsequent doses. Documentation includes lot numbers, units administered, start/stop times, and any adverse reactions for accurate billing of
J7197per international unit delivered.