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HCPCS Q5156 · Level II · Part B drug

HCPCS Q5156: Injection, tocilizumab-anoh (avtozma), 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 Q5156

Billing unit
1 MG
Inj, tocilizumab-anoh, 1 mg
ASP payment limit
$3.098
October 2026; -34.0% vs July 2026
Practitioner MUE
none published
CMS publishes no MUE for this code
OPPS status
SI K
APC 0950
NCCI exposure
no PTP pairs
Coverage articles
0
none list this code

TL;DR

HCPCS Q5156 is the Level II code for Injection, tocilizumab-anoh (avtozma), biosimilar, 1 mg, billed per 1 MG. The Medicare Part B ASP payment limit for October 2026 is $3.098 per billing unit, down 34.0% from July 2026. Under OPPS it carries status indicator K in APC 0950. 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 3 NDCs to it, sold as Avtozma by Celltrion USA, Inc.. No current Billing and Coding Article lists Q5156, so coverage follows the FDA label, compendia and any applicable NCD.

Medicare Part B payment limit (ASP)

CMS sets the Part B payment limit for Q5156 at $3.098 per 1 MG for October 2026, derived from manufacturer average sales price plus 6%, compared with $4.692 in July 2026. Beneficiary coinsurance is 20%.

ASP payment limits for Q5156
QuarterPayment limitPerCoinsurance
October 2026$3.0981 MG20%
July 2026$4.6921 MG—
CMS note: 8% of reference add-on applied

NDC to HCPCS billing-unit conversion

The October 2026 ASP crosswalk maps 3 NDCs from 1 labeler to Q5156. Report the NDC in the claim's drug segment and bill the number of Q5156 units that equals the quantity administered divided by 1 MG; the last column gives units per full package.

NDCs that crosswalk to Q5156
NDCDrug nameLabelerPackage sizeBilling units / package
72606-0042-01AvtozmaCelltrion USA, Inc.4 × 180
72606-0043-01AvtozmaCelltrion USA, Inc.10 × 1200
72606-0044-01AvtozmaCelltrion USA, Inc.20 × 1400

Medically Unlikely Edits (MUE)

CMS does not publish an MUE for Q5156 in the 2026 Q4 tables. Some MUE values are confidential and applied without publication, so unit limits can still deny; document the dose and the units calculation on every claim.

NCCI edits and add-on relationships

No active practitioner PTP pair lists Q5156 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.

Q5156 is neither an add-on code nor a designated primary code in the 2026 Q4 NCCI add-on edit file.

Medicare coverage articles

No current Billing and Coding Article lists Q5156 in its HCPCS table. Coverage then follows the drug's FDA label, compendia and any National Coverage Determination; check the Medicare Coverage Database before administering off-label.

Hospital outpatient (OPPS) status

In the July 2026 OPPS Addendum B, Q5156 carries status indicator K and is assigned to APC 0950, with a published national unadjusted payment of $4.69. Status K means the drug is paid separately under OPPS at the ASP-based rate rather than packaged into the procedure.

Common denials for Q5156 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 Q5156 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.

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Frequently asked questions — HCPCS Q5156

What does HCPCS code Q5156 describe?

Q5156 is defined by CMS as "Injection, tocilizumab-anoh (avtozma), 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 Q5156 in October 2026?

The ASP-based payment limit is $3.098 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 $4.692.

Which NDCs map to Q5156?

The October 2026 ASP crosswalk lists 3 NDCs from 1 labeler: Avtozma (Celltrion USA, Inc.). For example NDC 72606-0042-01 is a 4 package equal to 80 billing units. The crosswalk's billing-units-per-package figure converts each package into Q5156 units.

Does Q5156 have NCCI bundling edits?

No active practitioner PTP pairs list Q5156 as a column-1 or column-2 code in the v323r0 release. Unit limits (MUE) and medical-necessity coverage rules still apply.

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.