Q5104 HCPCS code: Injection, infliximab-abda, biosimilar, (renflexis), 10 mg
Q5104 is the HCPCS Level II code for injection, infliximab-abda, biosimilar, (renflexis), 10 mg. In 2024 Medicare paid an average of $22.95 per service for Q5104 across 861,596 services. Its Medicare coverage code is D (Special coverage instructions apply): Medicare covers it when its national or local coverage criteria are met. The NCCI unit limit is 150 per day on outpatient hospital claims. Medicare volume rose 16% from 2022 to 2024 (744,690 to 861,596 services). In 2024, about 1,840 clinicians billed Medicare for Q5104 for 3,352 beneficiaries; California, Minnesota, Florida accounted for 20% of services.
Code details
| Field | Value |
|---|---|
| Section | Q codes — Temporary codes |
| Coverage code | D — Special coverage instructions apply |
| Pricing indicator | 51 — Drug or biological (priced per ASP/average sales price rules) |
| BETOS category | O1E — Other drugs |
| Added | 2018-04-01 |
| Last action effective | 2018-04-01 |
Who bills Q5104 (2024)
| Measure | Value |
|---|---|
| Clinicians billing (by place of service) | 1,840 |
| Medicare beneficiaries | 3,352 |
| States with claims | 41 |
| Share of services in top 3 states (California, Minnesota, Florida) | 20% |
Counts only. Supplier and clinician names, contact lists and state-by-state detail are in Caduvo.
Medicare utilization for Q5104, 2022–2024
| Year | Services | Beneficiaries | Avg. allowed | Avg. paid |
|---|---|---|---|---|
| 2022 | 744,690 | 3,523 | $49.24 | $39.17 |
| 2023 | 1,108,164 | 4,478 | $36.70 | $29.10 |
| 2024 | 861,596 | 3,352 | $29.04 | $22.95 |
States with the most Q5104 services (2024)
| State | Services | Avg. paid |
|---|---|---|
| California | 68,480 | $23.06 |
| Minnesota | 54,716 | $22.64 |
| Florida | 49,234 | $23.48 |
| Michigan | 49,091 | $23.02 |
| Texas | 46,527 | $22.32 |
NCCI unit limits (MUE)
| Claim type | Max units per day | Rationale |
|---|---|---|
| outpatient hospital claims | 150 | Prescribing Information |
| practitioner claims | 150 | Prescribing Information |
Medicare policy articles for this code
- A52423: Billing and Coding: Infliximab and biosimilars (Wellpoint Federal (MAC - Part A, MAC - Part B))
- A56432: Billing and Coding: Infliximab (Palmetto GBA (MAC - Part A, MAC - Part B))
Covered diagnoses (692 ICD-10-CM codes)
The diagnoses most often listed as covered in the policy articles above:
| ICD-10-CM | Diagnosis | Articles listing it |
|---|---|---|
| D86.0 | Sarcoidosis of lung | 2 |
| D86.1 | Sarcoidosis of lymph nodes | 2 |
| D86.2 | Sarcoidosis of lung with sarcoidosis of lymph nodes | 2 |
| D86.3 | Sarcoidosis of skin | 2 |
| D86.81 | Sarcoid meningitis | 2 |
| D86.82 | Multiple cranial nerve palsies in sarcoidosis | 2 |
| D86.83 | Sarcoid iridocyclitis | 2 |
| D86.84 | Sarcoid pyelonephritis | 2 |
| D86.85 | Sarcoid myocarditis | 2 |
| D86.86 | Sarcoid arthropathy | 2 |
Showing 10 of 692. The full list, non-covered diagnoses and CSV export are in Caduvo.
What changed for Q5104
- 2018-04-01: Q5104 added to HCPCS Level II
- Next scheduled CMS quarterly update (HCPCS and DMEPOS fee schedule): 2027-01-01
Frequently asked questions
What is HCPCS code Q5104?
Q5104 is the HCPCS Level II code for injection, infliximab-abda, biosimilar, (renflexis), 10 mg. Short descriptor: "Injection, renflexis".
How much does Medicare pay for Q5104?
In 2024, the average Medicare payment was $22.95 per service (average allowed $29.04).
Does Medicare cover Q5104?
Coverage code D — Special coverage instructions apply. Medicare covers it when its national or local coverage criteria are met.
Which diagnoses support coverage for Q5104?
Medicare policy articles that cite Q5104 list 692 covered ICD-10-CM diagnosis codes across 2 articles. The most cited include D86.0 (Sarcoidosis of lung), D86.1 (Sarcoidosis of lymph nodes), D86.2 (Sarcoidosis of lung with sarcoidosis of lymph nodes). A listed diagnosis is necessary but not sufficient; the policy's other criteria still apply.
How many units of Q5104 can be billed per day?
150 on outpatient hospital claims; 150 on practitioner claims (NCCI medically unlikely edits).
Related Q51 codes
- Q5100 — Injection, ustekinumab-kfce (yesintek), biosimilar, 1 mg
- Q5101 — Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram
- Q5102 — Injection, infliximab, biosimilar, 10 mg
- Q5103 — Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg
- Q5105 — Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units
- Q5106 — Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units
- Q5107 — Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg
- Q5108 — Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg
- Q5109 — Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg
- Q5110 — Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram
- Q5111 — Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg
- Q5112 — Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg
Building a device that would bill under a code like this? Caduvo matches a device description to HCPCS/CPT codes, Medicare coverage and payment, and the FDA pathway in one report.
Next steps
- Run a reimbursement report for a device billed under Q5104
- Watch Q5104 for fee, coverage and descriptor changes
- Build a full Medicare revenue model for Q5104
Sources: CMS HCPCS Level II release October 2025; CMS DMEPOS fee schedule; CMS NCCI MUE tables; CMS Medicare utilization (physician and DME supplier files); CMS Medicare Coverage Database articles. Fees are Medicare allowables, not commercial rates. Not billing or legal advice.