Skip to main content
HCPCS Q5130 · Level II · Part B drug

HCPCS Q5130: Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg

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 Q5130

Billing unit
0.5 MG
Inj, fylnetra, 0.5 mg
ASP payment limit
$94.292
October 2026; -10.3% vs July 2026
Practitioner MUE
12
MAI 3
OPPS status
SI K
APC 9118
NCCI exposure
no PTP pairs
Coverage articles
1
4 states

TL;DR

HCPCS Q5130 is the Level II code for Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg, billed per 0.5 MG. The Medicare Part B ASP payment limit for October 2026 is $94.292 per billing unit, down 10.3% from July 2026. The practitioner MUE allows up to 12 units per date of service (MAI 3). Under OPPS it carries status indicator K in APC 9118. 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 1 NDC to it, sold as Fylnetra by Amneal Pharmaceuticals, LLC. 1 Medicare coverage article lists the code across 4 states, including .

Medicare Part B payment limit (ASP)

CMS sets the Part B payment limit for Q5130 at $94.292 per 0.5 MG for October 2026, derived from manufacturer average sales price plus 6%, compared with $105.109 in July 2026. Beneficiary coinsurance is 20%.

ASP payment limits for Q5130
QuarterPayment limitPerCoinsurance
October 2026$94.2920.5 MG20%
July 2026$105.1090.5 MG—
CMS note: 8% of reference add-on applied

NDC to HCPCS billing-unit conversion

The October 2026 ASP crosswalk maps 1 NDC from 1 labeler to Q5130. Report the NDC in the claim's drug segment and bill the number of Q5130 units that equals the quantity administered divided by 0.5 MG; the last column gives units per full package.

NDCs that crosswalk to Q5130
NDCDrug nameLabelerPackage sizeBilling units / package
70121-1627-01FylnetraAmneal Pharmaceuticals, LLC0.6 × 112

Medically Unlikely Edits (MUE)

CMS publishes 2 MUE values for Q5130. For practitioners the limit is 12 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 Q5130 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services123 Date of Service Edit: ClinicalPrescribing Information
Facility outpatient hospital123 Date of Service Edit: ClinicalPrescribing Information

NCCI edits and add-on relationships

No active practitioner PTP pair lists Q5130 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.

Q5130 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 Q5130 in their HCPCS tables, covering 4 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 Q5130
ArticleTitleContractor(s)StatesRelated LCD
Billing and Coding: White Cell Colony Stimulating FactorsPalmetto GBANC SC VA WVL37176

Hospital outpatient (OPPS) status

In the July 2026 OPPS Addendum B, Q5130 carries status indicator K and is assigned to APC 9118, with a published national unadjusted payment of $105.11. Status K means the drug is paid separately under OPPS at the ASP-based rate rather than packaged into the procedure.

Common denials for Q5130 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 Q5130 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 meeting

Frequently asked questions — HCPCS Q5130

What does HCPCS code Q5130 describe?

Q5130 is defined by CMS as "Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg". Each billing unit represents 0.5 MG, so the units reported on the claim must equal the dose administered divided by that unit.

What is the Medicare reimbursement for Q5130 in October 2026?

The ASP-based payment limit is $94.292 per 0.5 MG, with 20% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules. The July 2026 limit was $105.109.

How many units of Q5130 can be billed per day?

The practitioner Medically Unlikely Edit is 12 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 Q5130?

The October 2026 ASP crosswalk lists 1 NDC from 1 labeler: Fylnetra (Amneal Pharmaceuticals, LLC). For example NDC 70121-1627-01 is a 0.6 package equal to 12 billing units. The crosswalk's billing-units-per-package figure converts each package into Q5130 units.

Does Q5130 have NCCI bundling edits?

No active practitioner PTP pairs list Q5130 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 Q5130?

1 current Billing and Coding Article in the Medicare Coverage Database list Q5130, covering 4 states: (Billing and Coding: White Cell Colony Stimulating Factors).

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. 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.