Summary & Overview
HCPCS Q5145: Adalimumab-afzb (Abrilada), Biosimilar, 1 mg
HCPCS Level II code Q5145 designates the biosimilar product adalimumab-afzb (brand name Abrilada) at a unit dose of 1 mg. As biosimilars expand therapeutic options for autoimmune and inflammatory conditions, accurate coding for biologic supplies affects clinical workflows, inventory management, and payer reimbursement nationally. This code enables standardized reporting of the specific biosimilar product separate from originator or other biosimilar codes.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code’s clinical context and common sites of service, plus guidance on where to look for payer coverage policies and coding clarifications. The publication covers benchmarking topics such as typical billing scenarios, implications for drug administration and supply lines, and how biosimilar-specific HCPCS reporting interacts with payer policies and reimbursement frameworks.
This summary provides a concise reference for clinicians, revenue cycle staff, and policy analysts seeking clarity on how Q5145 is used in outpatient billing for adalimumab-afzb, and what areas to review when assessing coverage and billing practices.
Billing Code Overview
HCPCS Level II code Q5145 represents an injectable biosimilar formulation of adalimumab-afzb (brand name Abrilada), dosed and billed per 1 mg. This code is used to report administration or supply of the biosimilar drug product.
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Service type: Injectable biologic medication
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Typical site of service: Administration in outpatient settings such as physician offices, infusion centers, or hospital outpatient departments; may also be reported when supplied in other outpatient care settings
Clinical & Coding Specifications
Clinical Context
A 48-year-old patient with established moderate-to-severe rheumatoid arthritis presents to an outpatient infusion/injection clinic for scheduled biologic therapy. The patient has been prescribed adatimumab-afzb (abrilada) and receives a subcutaneous injection prepared as Q5145 (adalimumab-afzb, 1 mg). The clinical workflow includes verification of identity and prescription, review of allergies and current immunizations, assessment for active infection or recent live vaccines, documentation of baseline vitals, insurance and benefit verification, and appropriate administration technique (subcutaneous injection into the abdomen or thigh). The clinician documents lot number and expiration, provides patient education on injection site care and adverse effects, and schedules the next dose. Billing captures the HCPCS Level II product code Q5145, relevant diagnosis codes supporting medical necessity, and any applicable modifier(s) reflecting the service circumstances (for example, billing modifiers for unusual services, third‑party payor requirements, or provider-based specifics).
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | Procedure or service furnished in its entirety; no modifier |