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HCPCS Q5167 · Level II · Part B drug

HCPCS Q5167: Injection, denosumab-qbde (enoby/xtrenbo), 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 Q5167

Billing unit
1 MG
Inj, denosumab-qbde, 1 mg
ASP payment limit
$7.681
October 2026
Practitioner MUE
none published
CMS publishes no MUE for this code
OPPS status
SI K
APC 0949
NCCI exposure
no PTP pairs
Coverage articles
1
5 states

TL;DR

HCPCS Q5167 is the Level II code for Injection, denosumab-qbde (enoby/xtrenbo), biosimilar, 1 mg, billed per 1 MG. The Medicare Part B ASP payment limit for October 2026 is $7.681 per billing unit. Under OPPS it carries status indicator K in APC 0949. 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 Enoby, Xtrenbo by Hikma Pharmaceuticals USA 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 Q5167 at $7.681 per 1 MG for October 2026, derived from manufacturer average sales price plus 6%. Beneficiary coinsurance is 20%.

ASP payment limits for Q5167
QuarterPayment limitPerCoinsurance
October 2026$7.6811 MG20%
July 2026n/a1 MG—
CMS note: Added October 2026; 8% of reference add-on applied

NDC to HCPCS billing-unit conversion

The October 2026 ASP crosswalk maps 2 NDCs from 1 labeler to Q5167. Report the NDC in the claim's drug segment and bill the number of Q5167 units that equals the quantity administered divided by 1 MG; the last column gives units per full package.

NDCs that crosswalk to Q5167
NDCDrug nameLabelerPackage sizeBilling units / package
00143-9165-01EnobyHikma Pharmaceuticals USA Inc.1 × 160
00143-9166-01XtrenboHikma Pharmaceuticals USA Inc.1.7 × 1120

Medically Unlikely Edits (MUE)

CMS does not publish an MUE for Q5167 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 Q5167 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.

Q5167 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 Q5167 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 Q5167
ArticleTitleContractor(s)StatesRelated LCD
Billing and Coding: Denosumab (Prolia®, Xgeva®, Jubbonti®) and biosimilarsWellpoint FederalCT IL MN NY WIL33394

Hospital outpatient (OPPS) status

In the July 2026 OPPS Addendum B, Q5167 carries status indicator K and is assigned to APC 0949, with a published national unadjusted payment of $4.12. Status K means the drug is paid separately under OPPS at the ASP-based rate rather than packaged into the procedure.

Common denials for Q5167 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 Q5167 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 Q5167

What does HCPCS code Q5167 describe?

Q5167 is defined by CMS as "Injection, denosumab-qbde (enoby/xtrenbo), 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 Q5167 in October 2026?

The ASP-based payment limit is $7.681 per 1 MG, with 20% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules.

Which NDCs map to Q5167?

The October 2026 ASP crosswalk lists 2 NDCs from 1 labeler: Enoby (Hikma Pharmaceuticals USA Inc.); Xtrenbo (Hikma Pharmaceuticals USA Inc.). For example NDC 00143-9165-01 is a 1 package equal to 60 billing units. The crosswalk's billing-units-per-package figure converts each package into Q5167 units.

Does Q5167 have NCCI bundling edits?

No active practitioner PTP pairs list Q5167 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 Q5167?

1 current Billing and Coding Article in the Medicare Coverage Database list Q5167, covering 5 states: (Billing and Coding: Denosumab (Prolia®, Xgeva®, Jubbonti®) 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.