Summary & Overview
HCPCS Q5147: Aflibercept-ayyh (Pavblu) 1 mg Injection
HCPCS Level II code Q5147 designates a 1 mg dose of aflibercept-ayyh (Pavblu), a biosimilar anti-VEGF agent administered by injection for ophthalmic indications. This code identifies the specific biosimilar product and enables standardized reporting of medication use and billing for intravitreal therapies that target retinal vascular disease. Nationally, precise coding for biosimilar ophthalmic injectables matters for product tracking, formulary management, and reimbursement consistency across payers.
Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of what Q5147 represents clinically and operationally, payer coverage considerations, common billing modifiers, and the typical site-of-service context. The publication summarizes billing benchmarks where available, highlights relevant policy updates affecting biosimilar ophthalmic agents, and situates Q5147 within clinical workflow for outpatient ophthalmology clinics and ambulatory surgical centers.
This summary is intended to help coding professionals, practice administrators, and policy analysts understand the role of HCPCS Level II code Q5147 in medical billing, formulary decisions, and encounter documentation for intravitreal anti-VEGF therapy.
Billing Code Overview
HCPCS Level II code Q5147 represents an injection of aflibercept-ayyh (Pavblu), biosimilar, 1 mg. The service is an intravitreal or ocular injection of an anti-VEGF biosimilar used in ophthalmic care for retinal vascular conditions. The service type is an ophthalmic injectable medication administration, typically performed in an outpatient ophthalmology clinic or ambulatory surgical setting.
Clinical & Coding Specifications
Clinical Context
A typical patient is an older adult with neovascular (wet) age-related macular degeneration (AMD) or other retinal vascular diseases who presents to a retinal specialty clinic for intravitreal anti-VEGF therapy. The patient undergoes a focused ophthalmic exam including visual acuity, intraocular pressure check, slit-lamp and dilated fundus exam, and optical coherence tomography (OCT) imaging to document macular fluid or hemorrhage. After informed consent and topical anesthesia, the ophthalmologist or authorized injector prepares a sterile field in the procedure room or ambulatory surgery center. The provider administers an intravitreal injection of Q5147 (aflibercept-ayyh, biosimilar to Pavblu), typically 1 mg, into the vitreous cavity. Post-injection, the patient is monitored briefly for acute complications (elevated intraocular pressure, pain, signs of endophthalmitis) and given post-procedure instructions and follow-up arranged for OCT and visual acuity assessment at the recommended interval (often 4–8 weeks). Documentation includes indication, laterality, informed consent, medication lot number, dose, route, injection site, and post-procedure status.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier | Standard use when no applicable modifier applies |