Summary & Overview
HCPCS Level II S0104: Zidovudine, Oral, 100 mg
HCPCS Level II code S0104 identifies zidovudine, oral, 100 mg, a nucleoside reverse transcriptase inhibitor used in antiretroviral therapy. Nationally, accurate coding for antiretroviral medication supplies matters for clinical continuity, payer coverage determinations, and pharmacy reimbursement workflows. Proper use of S0104 supports claims processing for outpatient dispensing of zidovudine.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code's clinical role, common billing contexts, and where this code is typically reported on the claim line. The publication outlines benchmark considerations, payer coverage patterns, and coding nuances relevant to pharmacy and outpatient clinic billing operations.
The content provides concise guidance on the billing context for oral zidovudine 100 mg, expected service locations, and the types of information payers commonly require to adjudicate claims. Data not provided in the input—such as detailed payer-specific reimbursement rates, associated taxonomies, and ICD-10 pairings—is noted where applicable.
Billing Code Overview
HCPCS Level II code S0104 represents zidovudine, oral, 100 mg, an antiretroviral medication formulation. The service type is oral antiretroviral medication supply, and the typical site of service is outpatient pharmacy or outpatient clinic dispensing.
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Clinical & Coding Specifications
Clinical Context
A typical patient receiving S0104 (Zidovudine, oral, 100 mg) is an adult or pediatric patient living with human immunodeficiency virus (HIV) who requires oral antiretroviral therapy as part of combination regimens. Clinical workflow commonly begins with an infectious disease or primary care visit where diagnosis, baseline laboratory testing (HIV viral load, CD4 count, complete blood count, liver and renal panels), and resistance testing are reviewed. The prescriber documents the rationale for including zidovudine (e.g., part of a nucleoside reverse transcriptase inhibitor backbone, intolerance to alternative agents, pregnancy considerations) and writes an electronic prescription for the oral formulation.
Medication is dispensed by an outpatient pharmacy or specialty pharmacy; counseling on adherence, expected adverse effects (notably anemia, neutropenia, myopathy), and monitoring schedule is provided by a pharmacist or nurse. Follow-up includes periodic laboratory monitoring (CBC for cytopenias, liver function tests), assessment of tolerability, and viral load testing to evaluate efficacy. In peripartum or neonatal contexts, zidovudine oral dosing may be used for maternal therapy or neonatal post-exposure prophylaxis per institutional protocols. Billing uses HCPCS Level II S0104 for the medication when appropriate payer policies require reporting of HCPCS codes for oral drugs supplied in certain programs or outpatient settings.
Coding Specifications
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