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HCPCS Q5147 · Level II · Part B drug

HCPCS Q5147: Injection, aflibercept-ayyh (pavblu), biosimilar, 1 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 Q5147

Billing unit
1 MG
Inj, aflibercept-ayyh, 1 mg
ASP payment limit
$763.376
October 2026; -5.0% vs July 2026
Practitioner MUE
4
MAI 2
OPPS status
SI G
APC 2068
NCCI exposure
no PTP pairs
Coverage articles
1
5 states

TL;DR

HCPCS Q5147 is the Level II code for Injection, aflibercept-ayyh (pavblu), biosimilar, 1 mg, billed per 1 MG. The Medicare Part B ASP payment limit for October 2026 is $763.376 per billing unit, down 5.0% from July 2026. The practitioner MUE allows up to 4 units per date of service (MAI 2). Under OPPS it carries status indicator G in APC 2068. 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. With a 1 mg billing unit, a single administration can be hundreds of units; the unit count on the claim must equal the milligrams given, and rounding rules for partial units follow the contractor's guidance. The ASP crosswalk maps 2 NDCs to it, sold as Pavblu by Amgen Inc. 1 Medicare coverage article lists the code across 5 states, including .

Medicare Part B payment limit (ASP)

CMS sets the Part B payment limit for Q5147 at $763.376 per 1 MG for October 2026, derived from manufacturer average sales price plus 6%, compared with $803.255 in July 2026. Beneficiary coinsurance is 20%.

ASP payment limits for Q5147
QuarterPayment limitPerCoinsurance
October 2026$763.3761 MG20%
July 2026$803.2551 MG—
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 2 NDCs from 1 labeler to Q5147. Report the NDC in the claim's drug segment and bill the number of Q5147 units that equals the quantity administered divided by 1 MG; the last column gives units per full package.

NDCs that crosswalk to Q5147
NDCDrug nameLabelerPackage sizeBilling units / package
55513-0056-01PavbluAmgen Inc0.05 × 12
55513-0065-01PavbluAmgen Inc0.05 × 12

Medically Unlikely Edits (MUE)

CMS publishes 3 MUE values for Q5147. For practitioners the limit is 4 units per date of service with adjudication indicator 2, a date-of-service policy edit: the limit reflects CMS policy and units above it deny even if split across lines; appeals rarely succeed.

MUE values for Q5147 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services42 Date of Service Edit: PolicyAnatomic Consideration
Facility outpatient hospital42 Date of Service Edit: PolicyAnatomic Consideration
DME supplier42 Date of Service Edit: PolicyAnatomic Consideration

NCCI edits and add-on relationships

No active practitioner PTP pair lists Q5147 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.

Q5147 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 Q5147 in their HCPCS tables, covering 5 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 Q5147
ArticleTitleContractor(s)StatesRelated LCD
Billing and Coding: Ranibizumab, Aflibercept and biosimilarsWellpoint FederalCT IL MN NY WIL33394

Hospital outpatient (OPPS) status

In the July 2026 OPPS Addendum B, Q5147 carries status indicator G and is assigned to APC 2068, with a published national unadjusted payment of $803.26. Status G marks pass-through drug payment, which is time-limited.

Common denials for Q5147 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 Q5147 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 Q5147

What does HCPCS code Q5147 describe?

Q5147 is defined by CMS as "Injection, aflibercept-ayyh (pavblu), biosimilar, 1 mg". Each billing unit represents 1 MG, so the units reported on the claim must equal the dose administered divided by that unit.

What is the Medicare reimbursement for Q5147 in October 2026?

The ASP-based payment limit is $763.376 per 1 MG, with 20% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules. The July 2026 limit was $803.255.

How many units of Q5147 can be billed per day?

The practitioner Medically Unlikely Edit is 4 units per date of service with adjudication indicator 2 (2 Date of Service Edit: Policy). MAI 2 edits are policy limits and are rarely overturned on appeal. CMS cites "Anatomic Consideration" as the rationale.

Which NDCs map to Q5147?

The October 2026 ASP crosswalk lists 2 NDCs from 1 labeler: Pavblu (Amgen Inc). For example NDC 55513-0056-01 is a 0.05 package equal to 2 billing units. The crosswalk's billing-units-per-package figure converts each package into Q5147 units.

Does Q5147 have NCCI bundling edits?

No active practitioner PTP pairs list Q5147 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 Q5147?

1 current Billing and Coding Article in the Medicare Coverage Database list Q5147, covering 5 states: (Billing and Coding: Ranibizumab, Aflibercept and biosimilars).

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.