Summary & Overview
HCPCS J9395: Injection, Fulvestrant 25 mg
HCPCS Level II code J9395 denotes a 25 mg injection of fulvestrant, an estrogen receptor antagonist used in oncology. This nationally relevant billing code captures administration of a specialty injectable drug commonly delivered in outpatient infusion settings, physician offices, and hospital outpatient departments. Accurate reporting of J9395 affects drug utilization tracking, claim adjudication, and payment for cancer therapies.
Key payers covered in this overview include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find information on the clinical context for fulvestrant administration, common sites of service, and the range of modifiers typically applied to injectable drug administration claims. The publication outlines benchmarks and billing considerations relevant to payers and providers, highlights common variations in coverage and coding practice, and summarizes policy updates that influence claim processing for specialty oncology drugs.
The summary provides practical reference material for billing teams, revenue cycle managers, and compliance staff seeking clarity on how J9395 is used in claims. Data not provided in the input—such as specific payer policies, reimbursement rates, and associated ICD-10 diagnoses—are noted as unavailable where applicable.
Billing Code Overview
HCPCS Level II code J9395 represents an injectable oncology medication, fulvestrant, 25 mg. This code is used to report administration of a 25 mg dose of fulvestrant provided as an injection.
Service type: Drug administration (injectable oncology therapy)
Typical site of service: Hospital outpatient, physician office, outpatient infusion center, or other ambulatory care settings
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is a postmenopausal woman with hormone receptor–positive metastatic or locally advanced estrogen receptor–positive breast cancer who requires aromatase-inhibitor or tamoxifen–resistant endocrine therapy. The patient presents to an oncology infusion clinic for intramuscular administration of J9395 (fulvestrant, 25 mg). The clinical workflow includes verification of the oncology treatment plan and prescription, medication reconciliation, informed consent discussion documenting risks and benefits, screening for active infections and coagulation status, and pre-medication if clinically indicated. The nurse performs medication preparation under aseptic technique, confirms patient identity and site of injection (typically gluteal intramuscular), administers the injection, and monitors the patient for immediate adverse reactions for 15–30 minutes. Vital signs and drug lot/expiration are documented in the medical record. Follow-up oncology visits are scheduled to assess response, manage adverse effects, and plan subsequent doses per the fulvestrant dosing schedule.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service on same day as procedure | Use when a qualifying E/M visit is performed and documented on the same day as J9395 administration. |