Summary & Overview
HCPCS Q5104: Infliximab-abda (Renflexis), 10 mg injection
HCPCS Level II code Q5104 denotes the biosimilar infliximab-abda (Renflexis) in a 10 mg unit vial for parenteral administration. The code is used by outpatient infusion centers and hospital outpatient departments to bill for the biologic agent itself when administered as an intravenous infusion. Nationally, biosimilar infliximab products affect biologic utilization patterns and cost-management efforts across commercial insurers and Medicare.
Key payers included in coverage comparisons are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides a concise view of how this code is used for billing the drug product, typical sites of service, and payer coverage context.
Readers will find benchmarks and operational guidance on claims coding for the drug product line, summaries of common modifier usage (input provided), and clinical context about infusion-based biologic therapy. The document highlights policy considerations relevant to biosimilar adoption, reimbursement coding practices for drug acquisition versus administration, and practical billing elements for outpatient infusion services. Data not available in the input is explicitly noted where applicable.
Billing Code Overview
HCPCS Level II code Q5104 represents injection, infliximab-abda, biosimilar (Renflexis), 10 mg. This code denotes a biologic biosimilar formulation of infliximab supplied for parenteral administration.
-
Service type: Intravenous biologic therapy (infusion)
-
Typical site of service: Outpatient infusion clinic or hospital outpatient department
Clinical & Coding Specifications
Clinical Context
A typical patient receiving Q5104 is an adult with an immune-mediated inflammatory disease such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, Crohn disease, or ulcerative colitis who requires maintenance intravenous biologic therapy with an infliximab biosimilar (renflexis). The clinical workflow begins with a physician visit by a rheumatologist, gastroenterologist, or infusion center medical director who documents indication, prior response to therapy, weight-based dosing calculation, and screening for active infections (including tuberculosis and hepatitis B). Prior authorization is frequently obtained from payors including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthCare, BUCA, or Medicare. On the infusion day the patient is triaged, vital signs recorded, premedication ordered as needed (acetaminophen, antihistamine, corticosteroid), and an intravenous line placed by a registered nurse. The Q5104 drug vial is prepared by pharmacy, delivered to the infusion suite, administered per product-specific infusion rate with monitoring for infusion reactions, and post-infusion observation is performed. Documentation includes medication name infliximab-abda (renflexis), NDC and lot number, dose in mg, infusion start and stop times, patient tolerance, and any concurrent administration codes or modifiers (for example reporting wasted drug using JW when applicable). Billing is submitted to the patient’s primary insurer with the appropriate HCPCS code Q5104, diagnosis code(s) supporting medical necessity, and relevant modifiers for payment circumstances or administration complexities.