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HCPCS Q5105 · Level II · Part B drug

HCPCS Q5105: Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis),

Reviewed by QuickIntell RCM Editorial Team · Last reviewed

Data effective
Data currency: ASP payment limits October 2026 (effective October 1, 2026); MUE and NCCI edits 2026 Q4 (effective October 1, 2026); OPPS Addendum B July 2026 (effective July 1, 2026). Next CMS release: January 1, 2027 (ASP, MUE, NCCI and OPPS quarterly updates).

Key facts for Q5105

Billing unit
100 UNITS
Inj retacrit esrd on dialysi
ASP payment limit
$0.817
October 2026; +2.5% vs July 2026
Practitioner MUE
100
MAI 3
OPPS status
SI N
NCCI exposure
no PTP pairs
Coverage articles
1
2 states

TL;DR

HCPCS Q5105 is the Level II code for Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis),, billed per 100 UNITS. The Medicare Part B ASP payment limit for October 2026 is $0.817 per billing unit, up 2.5% from July 2026. The practitioner MUE allows up to 100 units per date of service (MAI 3). Under OPPS it carries status indicator N. Because the descriptor is specific to ESRD patients on dialysis, Medicare expects the drug inside the ESRD prospective payment bundle when furnished by the dialysis facility, and separate Part B billing applies only outside that setting. As a biosimilar it has its own code and ASP; the reference product cannot be billed under this code, and the JZ or JW modifier rules for discarded amounts apply per single-dose vial. The ASP crosswalk maps 12 NDCs to it, sold as Retacrit by Pfizer Inc, Vifor (International) Inc.. 1 Medicare coverage article lists the code across 2 states, including .

Medicare Part B payment limit (ASP)

CMS sets the Part B payment limit for Q5105 at $0.817 per 100 UNITS for October 2026, derived from manufacturer average sales price plus 6%, compared with $0.797 in July 2026. Beneficiary coinsurance is 20%.

ASP payment limits for Q5105
QuarterPayment limitPerCoinsurance
October 2026$0.817100 UNITS20%
July 2026$0.797100 UNITS—
Source: CMS Medicare Part B Drug Payment Limit File. Commercial and Medicaid payers set their own rates.

NDC to HCPCS billing-unit conversion

The October 2026 ASP crosswalk maps 12 NDCs from 2 labelers to Q5105. Report the NDC in the claim's drug segment and bill the number of Q5105 units that equals the quantity administered divided by 100 UNITS; the last column gives units per full package.

NDCs that crosswalk to Q5105
NDCDrug nameLabelerPackage sizeBilling units / package
00069-1305-10RetacritPfizer Inc1 × 10200
00069-1306-10RetacritPfizer Inc1 × 10300
00069-1307-10RetacritPfizer Inc1 × 10400
00069-1308-10RetacritPfizer Inc1 × 101000
00069-1309-04RetacritPfizer Inc1 × 41600
00069-1311-10RetacritPfizer Inc1 × 102000
00069-1318-10RetacritPfizer Inc2 × 101000
59353-0002-10RetacritVifor (International) Inc.1 × 10200
59353-0003-10RetacritVifor (International) Inc.1 × 10300
59353-0004-10RetacritVifor (International) Inc.1 × 10400
59353-0120-10RetacritVifor (International) Inc.1 × 102000
59353-0220-10RetacritVifor (International) Inc.2 × 101000

Medically Unlikely Edits (MUE)

CMS publishes 2 MUE values for Q5105. For practitioners the limit is 100 units per date of service with adjudication indicator 3, a date-of-service clinical edit: units above the limit deny but can be paid on appeal with documentation that the quantity was medically reasonable.

MUE values for Q5105 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services1003 Date of Service Edit: ClinicalClinical: Data
Facility outpatient hospital4003 Date of Service Edit: ClinicalClinical: Data

NCCI edits and add-on relationships

No active practitioner PTP pair lists Q5105 as a column-1 or column-2 code in v323r0. Drug supply codes are rarely bundled; the administration codes billed with them are where PTP edits usually apply.

Q5105 is neither an add-on code nor a designated primary code in the 2026 Q4 NCCI add-on edit file.

Medicare coverage articles

1 current Medicare Administrative Contractor article lists Q5105 in their HCPCS tables, covering 2 states. Each article carries the covered and non-covered ICD-10 codes that medical-necessity denials (CARC 50) are adjudicated against.

Billing and Coding Articles listing Q5105
ArticleTitleContractor(s)StatesRelated LCD
Billing and Coding: Erythropoiesis Stimulating Agents (ESA)CGS Administrators, LLCKY OHL34356

Hospital outpatient (OPPS) status

In the July 2026 OPPS Addendum B, Q5105 carries status indicator N. Status N means payment is packaged into the associated procedure and no separate OPPS payment is made.

Common denials for Q5105 and how to prevent them

CARC 16 · M119

NDC missing, invalid or not matched to the HCPCS code

CARC 151 · N362

units billed exceed the MUE for the date of service

CARC 50 · N115

diagnosis not covered by the applicable coverage article or LCD

How QuickIntell checks Q5105 before the claim leaves

QuickCode validates the NDC-to-unit conversion against the current ASP crosswalk, checks units against every published MUE setting and flags PTP and add-on conflicts on the same claim. QuickRCM routes CARC 16, 151 and 50 denials on drug lines with the matching coverage article attached so the appeal starts with evidence.

Explore QuickCodeExplore QuickRCMBook a demo

Frequently asked questions — HCPCS Q5105

What does HCPCS code Q5105 describe?

Q5105 is defined by CMS as "Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis),". Each billing unit represents 100 UNITS, so the units reported on the claim must equal the dose administered divided by that unit.

What is the Medicare reimbursement for Q5105 in October 2026?

The ASP-based payment limit is $0.817 per 100 UNITS, with 20% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules. The July 2026 limit was $0.797.

How many units of Q5105 can be billed per day?

The practitioner Medically Unlikely Edit is 100 units per date of service with adjudication indicator 3 (3 Date of Service Edit: Clinical). MAI 3 edits can be appealed with documentation that the units were medically reasonable. CMS cites "Clinical: Data" as the rationale.

Which NDCs map to Q5105?

The October 2026 ASP crosswalk lists 12 NDCs from 2 labelers: Retacrit (Pfizer Inc); Retacrit (Vifor (International) Inc.). For example NDC 00069-1305-10 is a 1 package equal to 200 billing units. The crosswalk's billing-units-per-package figure converts each package into Q5105 units.

Does Q5105 have NCCI bundling edits?

No active practitioner PTP pairs list Q5105 as a column-1 or column-2 code in the v323r0 release. Unit limits (MUE) and medical-necessity coverage rules still apply.

Which Medicare coverage articles mention Q5105?

1 current Billing and Coding Article in the Medicare Coverage Database list Q5105, covering 2 states: (Billing and Coding: Erythropoiesis Stimulating Agents (ESA)).

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-01. Verify against the primary file before billing or contracting decisions.

Disclaimer

This page is an operational reference compiled from CMS publications: the Medicare Part B drug payment limit and NDC crosswalk files, NCCI MUE and add-on edit tables, aggregate PTP statistics, OPPS Addendum B and the Medicare Coverage Database. Payment limits are Medicare national amounts; commercial and Medicaid payers differ. CPT codes are shown as numbers only; CPT descriptors are copyright AMA. Nothing here is legal, clinical or billing advice.