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HCPCS Q5106 · Level II · Part B drug

HCPCS Q5106: Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000

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 Q5106

Billing unit
1000 UNITS
Inj retacrit non-esrd use
ASP payment limit
$8.171
October 2026; +2.6% vs July 2026
Practitioner MUE
60
MAI 3
OPPS status
SI K
APC 9097
NCCI exposure
no PTP pairs
Coverage articles
1
2 states

TL;DR

HCPCS Q5106 is the Level II code for Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000, billed per 1000 UNITS. The Medicare Part B ASP payment limit for October 2026 is $8.171 per billing unit, up 2.6% from July 2026. The practitioner MUE allows up to 60 units per date of service (MAI 3). Under OPPS it carries status indicator K in APC 9097. The descriptor restricts this code to non-ESRD use; the ESRD-on-dialysis counterpart is a separate code and billing the wrong one is a frequent reason for CARC 16 returns. 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 Q5106 at $8.171 per 1000 UNITS for October 2026, derived from manufacturer average sales price plus 6%, compared with $7.968 in July 2026. Beneficiary coinsurance is 20%.

ASP payment limits for Q5106
QuarterPayment limitPerCoinsurance
October 2026$8.1711000 UNITS20%
July 2026$7.9681000 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 Q5106. Report the NDC in the claim's drug segment and bill the number of Q5106 units that equals the quantity administered divided by 1000 UNITS; the last column gives units per full package.

NDCs that crosswalk to Q5106
NDCDrug nameLabelerPackage sizeBilling units / package
00069-1305-10RetacritPfizer Inc1 × 1020
00069-1306-10RetacritPfizer Inc1 × 1030
00069-1307-10RetacritPfizer Inc1 × 1040
00069-1308-10RetacritPfizer Inc1 × 10100
00069-1309-04RetacritPfizer Inc1 × 4160
00069-1311-10RetacritPfizer Inc1 × 10200
00069-1318-10RetacritPfizer Inc2 × 10100
59353-0002-10RetacritVifor (International) Inc.1 × 1020
59353-0003-10RetacritVifor (International) Inc.1 × 1030
59353-0004-10RetacritVifor (International) Inc.1 × 1040
59353-0120-10RetacritVifor (International) Inc.1 × 10200
59353-0220-10RetacritVifor (International) Inc.2 × 10100

Medically Unlikely Edits (MUE)

CMS publishes 2 MUE values for Q5106. For practitioners the limit is 60 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 Q5106 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services603 Date of Service Edit: ClinicalPrescribing Information
Facility outpatient hospital603 Date of Service Edit: ClinicalPrescribing Information

NCCI edits and add-on relationships

No active practitioner PTP pair lists Q5106 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.

Q5106 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 Q5106 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 Q5106
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, Q5106 carries status indicator K and is assigned to APC 9097, with a published national unadjusted payment of $7.97. Status K means the drug is paid separately under OPPS at the ASP-based rate rather than packaged into the procedure.

Common denials for Q5106 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 Q5106 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 Q5106

What does HCPCS code Q5106 describe?

Q5106 is defined by CMS as "Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000". Each billing unit represents 1000 UNITS, so the units reported on the claim must equal the dose administered divided by that unit.

What is the Medicare reimbursement for Q5106 in October 2026?

The ASP-based payment limit is $8.171 per 1000 UNITS, with 20% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules. The July 2026 limit was $7.968.

How many units of Q5106 can be billed per day?

The practitioner Medically Unlikely Edit is 60 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 "Prescribing Information" as the rationale.

Which NDCs map to Q5106?

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 20 billing units. The crosswalk's billing-units-per-package figure converts each package into Q5106 units.

Does Q5106 have NCCI bundling edits?

No active practitioner PTP pairs list Q5106 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 Q5106?

1 current Billing and Coding Article in the Medicare Coverage Database list Q5106, 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.