J9203 Gemtuzumab Ozogamicin Reimbursement | OpenPayer

Summary & Overview

HCPCS Level II J9203: Gemtuzumab Ozogamicin Injection, 0.1 mg

HCPCS Level II code J9203 identifies a 0.1 mg injection of gemtuzumab ozogamicin, a targeted chemotherapeutic agent used in oncology. This billing code matters nationally because it standardizes reporting for drug acquisition and administration costs, supports accurate reimbursement for infused oncology therapies, and facilitates monitoring of utilization and safety across outpatient and hospital infusion settings. Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

Readers will learn what the code represents clinically and operationally, which payers commonly process claims for this medication, and what information is typically examined when benchmarking and reviewing coverage policy for high-cost oncology injectables. The publication provides context on expected service lines (chemotherapy/drug administration), typical sites of service (outpatient infusion centers and hospital outpatient departments), and how the code is used in billing workflows. Where available, benchmarks and policy summaries outline reimbursement considerations, prior authorization trends, and documentation elements relevant to claim adjudication. Data not available in the input are explicitly noted so readers can identify gaps that may require payer policy review or supplemental sources.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareJ9203HCPCS Level IIgemtuzumab ozogamicinoncologychemotherapyinfusiondrug-administrationoutpatient-infusion

Billing Code Overview

HCPCS Level II code J9203 describes an injection of gemtuzumab ozogamicin, 0.1 mg. This code represents a chemotherapy agent dose administered by injection. The service type is drug administration/chemotherapy dosing. The typical site of service is outpatient infusion center or hospital outpatient department when provided as part of systemic anticancer therapy.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 62-year-old patient with relapsed or refractory CD33-positive acute myeloid leukemia (AML) presents to an outpatient oncology infusion center for administration of targeted antibody-drug conjugate therapy. The prescribing hematologist/oncologist has ordered gemtuzumab ozogamicin dosed per body weight, supplied and billed in 0.1 mg increments as J9203. Prior to infusion, the patient undergoes standard pre-infusion assessment including vital signs, review of prior laboratory results (complete blood count, liver function tests), verification of platelet and coagulation status, and confirmation of premedication orders to mitigate infusion-related reactions. The infusion nurse prepares the medication according to the pharmacy compounding protocol and administers it via peripheral IV or central venous access over the institution-specified infusion time. Post-infusion observation for infusion reactions and monitoring for hepatotoxicity and delayed cytopenias occurs at regular intervals; follow-up visits with the treating hematologist determine additional doses based on response and tolerability. Billing is performed per 0.1 mg unit using J9203, with modifiers applied as appropriate to reflect circumstances such as professional services, patient status, wastage, or billing exceptions.

Coding Specifications

Modifier	Description	When to Use
`JW`

Related Codes

HCPCS-J9176-ELOTUZUMAB-INJECTION-1MG

HCPCS Level II J9176: Injection, elotuzumab, 1 mg

HCPCS-J9038-AXATILIMAB-CSFR-INJECTION-0-1-MG

HCPCS J9038: Injection, axatilimab-csfr, 0.1 mg

HCPCS-J9272-DOSTARLIMAB-INJECTION-10MG

HCPCS J9272: Injection, dostarlimab-gxly, 10 mg

HCPCS-J9173-DURVALUMAB-INJECTION-10MG-INFUSION-THERAPY

HCPCS J9173: Durvalumab Injection, 10 mg

HCPCS-J9356-TRASTUZUMAB-HYALURONIDASE-SUBCUTANEOUS-INJECTION

HCPCS Level II J9356: Trastuzumab with Hyaluronidase, Subcutaneous Injection

HCPCS-J9353-MARGETUXIMAB-INJECTION-5MG

HCPCS J9353: Injection, margetuximab-cmkb, 5 mg

HCPCS-J9275-COSIBELIMAB-INJECTION-2MG

HCPCS J9275: Injection of cosibelimab-ipdl, 2 mg

HCPCS-J9045-CARBOPLATIN-INJECTION-50MG

HCPCS J9045: Injection, Carboplatin, 50 mg

HCPCS-J9037-BELANTAMAB-MAFODOTIN-INJECTION-05-MG

HCPCS J9037: Injection, belantamab mafodotin-blmf, 0.5 mg

HCPCS-J9056-BENDAMUSTINE-INJECTION-1MG

HCPCS J9056: Bendamustine Hydrochloride Injection, 1 mg

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Taxonomy Code	Specialty	Notes
`208000000X`	Hematology & Oncology	Hematologist/oncologist prescribes and oversees gemtuzumab ozogamicin therapy.
`352600000X`	Hematology	Hematologist manages leukemia diagnosis, response assessment, and toxicity monitoring.
`363LP0800X`	Oncology Nurse Practitioner	Advanced practice provider who may manage pre- and post-infusion assessment and follow-up.
`363A00000X`	Physician Assistant - Oncology	May perform infusion monitoring and documentation under supervising physician.
`164W00000X`	Oncology Pharmacist	Prepares and verifies chemotherapy compounding, dosing calculations, and stability documentation.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C92.0`	Acute myeloblastic leukemia with maturation	Represents a subtype of AML for which targeted anti-CD33 therapy like gemtuzumab may be used in relapsed or refractory settings.
`C92.5`	Acute myelomonocytic leukemia	AML subtype that can express CD33 and may be an indication for gemtuzumab ozogamicin in appropriate clinical contexts.
`C93.0`	Acute monoblastic and monocytic leukemia	Relevant when disease expresses CD33 and systemic therapy including gemtuzumab is considered.
`C94.0`	Acute erythroid leukemia	Less common but listed among acute leukemias evaluated for targeted agents when CD33 expression is present.
`Z51.11`	Encounter for antineoplastic chemotherapy	Used to indicate the visit is for administration of chemotherapy, appropriate for billing of infusion such as `J9203`.
`D61.810`	Transfusion-associated graft-versus-host disease	Included as a relevant complication to monitor in hematologic oncology patients receiving systemic therapies.
`R65.21`	Severe sepsis with septic shock	Included as a potential severe adverse event or comorbidity impacting administration decisions and billing modifiers for discontinued service.
`T88.1`	Other complications of infusion, transfusion and therapeutic injection	Captures infusion-related adverse reactions that may necessitate stopping the infusion and use of modifier `53` or `52`.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`96413`	Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug	Commonly billed for the IV infusion time associated with administration of gemtuzumab ozogamicin when infusion duration is up to 1 hour.
`96415`	Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary infusion)	Billed when the infusion time for gemtuzumab ozogamicin exceeds the initial hour and additional time increments apply.
`96417`	Chemotherapy administration, additional sequential infusion for chemotherapy, per day	Used when multiple, distinct sequential infusions are administered on the same day as part of the chemotherapy regimen.
`96365`	Intravenous infusion for therapy, prophylaxis, or diagnosis; initial, up to 1 hour	Sometimes used for non-chemotherapy or supportive IV infusions given in conjunction with chemotherapy (e.g., hydration, antiemetics) during the visit.
`96401`	Chemotherapy administration, intravenous push, single or initial substance/drug	Used if a bolus IV push of supportive medication is administered as part of the chemotherapy visit (not for the gemtuzumab infusion itself which is typically a longer infusion).
`96360`	Intravenous replacement fluids, initial 31 minutes to 1 hour	Billed when IV fluids are administered during the infusion visit as supportive care.