Summary & Overview
HCPCS J7204: Recombinant Factor VIII (EsperaCT), Glycopegylated, per IU
HCPCS Level II code J7204 designates an injectable recombinant factor VIII product (EsperaCT), glycopegylated, billed per international unit for treatment of hemophilia A. The code captures provision of a long-acting antihemophilic factor used for prophylaxis and management of bleeding episodes. Nationally, coverage and payment for high-cost biologic factor products carry implications for specialty pharmacy, infusion services, and payer formularies due to supply, dosing variability, and clinical necessity.
Key payers addressed in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise review of clinical context for factor VIII replacement, typical sites of service for administration, and an overview of payer coverage patterns. The publication summarizes available benchmarks for utilization and reimbursement, highlights policy and coding considerations relevant to billing per international unit, and outlines common billing modifiers and administrative factors affecting claims processing.
This summary is intended to orient billing staff, revenue cycle teams, infusion clinicians, and policy analysts to the purpose of J7204, common operational settings, and the payer landscape that influences access to recombinant factor VIII therapies.
Billing Code Overview
HCPCS Level II code J7204 represents an injection of factor VIII, antihemophilic factor (recombinant), (EsperaCT), glycopegylated-EXEI, billed per IU. This code is used for administration of a recombinant factor VIII concentrate formulated for patients with hemophilia A who require replacement therapy to prevent or control bleeding.
Service Type: Injectable biologic therapy (replacement factor VIII)
Typical Site of Service: Hospital outpatient infusion center, ambulatory infusion clinic, specialty infusion center, or physician office administering intravenous biologic therapy
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult male or female with moderate to severe hemophilia A presenting for prophylactic or on-demand replacement therapy with recombinant factor VIII (glycopegylated, brand Esperoct). The patient arrives at an outpatient infusion center, hematology clinic, or hospital outpatient department for intravenous administration of J7204 dosed in international units (IU) based on weight and clinical target factor level. Clinical workflow: review of recent bleed history and factor levels by the hematology nurse or pharmacist; verification of prescription and insurance authorization; venous access assessment (peripheral IV or port); reconstitution/dosing by pharmacy or infusion nurse; administration and monitoring for infusion reactions and efficacy; documentation of lot number, units administered, and any acute adverse events; discharge with home infusion instructions or scheduling of next prophylaxis as appropriate. Typical sites of service include outpatient infusion centers, hematology clinics, and hospital outpatient infusion units. Common scenarios include routine prophylaxis to prevent spontaneous bleeding, treatment of acute joint or muscle bleeds, perioperative management for minor procedures, or management of breakthrough bleeding despite prophylaxis.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | Default/No modifier | Used when no other modifier applies. |