Summary & Overview
HCPCS S0136: Clozapine, 25 mg
HCPCS Level II code S0136 denotes clozapine 25 mg and is used when billing for this specific medication strength in outpatient settings. Clozapine is a key treatment for treatment-resistant schizophrenia and is nationally significant due to its specialized monitoring requirements and role in reducing severe psychiatric symptoms when other antipsychotics fail. This code enables standardized reporting and payment for the 25 mg formulation across payers.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of clinical context for clozapine use, how the HCPCS Level II code maps to pharmaceutical billing, and the implications for outpatient pharmacy and clinic workflows. The publication outlines benchmarking concepts, common payer coverage considerations, and relevant policy or billing nuances tied to HCPCS reporting for specialty psychotropic medications.
This summary provides a concise national perspective on coding and billing for clozapine 25 mg, what stakeholders should expect in terms of where and how the code is used, and which payers are commonly involved in coverage decisions and reimbursement processes. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code S0136 represents Clozapine, 25 mg, an antipsychotic medication formulation. The service type is pharmaceutical administration / drug supply, reflecting billing for the specific medication strength rather than a procedure. The typical site of service for this billing code is outpatient pharmacies or outpatient clinics where clozapine is dispensed or administered to patients receiving ongoing treatment for treatment-resistant schizophrenia or related indications.
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Clinical & Coding Specifications
Clinical Context
A typical patient is an adult with treatment-resistant schizophrenia or schizoaffective disorder who requires clozapine therapy due to inadequate response or intolerance to other antipsychotics. The patient presents to an outpatient clinic or specialty pharmacy for dispensation of oral clozapine S0136 (25 mg). Clinical workflow includes baseline evaluation (medical history, smoking status, ECG if indicated, baseline labs including complete blood count with differential and absolute neutrophil count), enrollment in a clozapine risk evaluation and mitigation strategy (REMS) program, initiation or continuation of a titration schedule, counseling on side effects and agranulocytosis risk, scheduling of routine ANC monitoring (typically weekly then biweekly then monthly as per protocol), coordination with pharmacy for supply and prior authorization with payors if required, and documentation of dispensing and monitoring in the medical record. Typical site of service is outpatient clinic, community mental health center, or specialty pharmacy. A realistic patient scenario: a 32-year-old patient with schizophrenia who failed two prior antipsychotics is started on clozapine; the clinician prescribes S0136 25 mg tablets for dose titration and arranges REMS enrollment and weekly ANC checks during initiation.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
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