Q5130 HCPCS code: Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg
Q5130 is the HCPCS Level II code for injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg. In 2024 Medicare paid an average of $152.94 per service for Q5130 across 69,838 services. Its Medicare coverage code is C (Carrier judgment): Coverage is decided by the Medicare contractor (MAC) case by case. The NCCI unit limit is 12 per day on outpatient hospital claims. Medicare volume rose 660% from 2023 to 2024 (9,184 to 69,838 services). In 2024, about 516 clinicians billed Medicare for Q5130 for 1,617 beneficiaries; California, Maryland, Nebraska accounted for 30% of services.
Code details
| Field | Value |
|---|---|
| Section | Q codes — Temporary codes |
| Coverage code | C — Carrier judgment |
| Pricing indicator | 51 — Drug or biological (priced per ASP/average sales price rules) |
| BETOS category | O1E — Other drugs |
| Added | 2023-04-01 |
| Last action effective | 2023-04-01 |
Who bills Q5130 (2024)
| Measure | Value |
|---|---|
| Clinicians billing (by place of service) | 516 |
| Medicare beneficiaries | 1,617 |
| States with claims | 27 |
| Share of services in top 3 states (California, Maryland, Nebraska) | 30% |
Counts only. Supplier and clinician names, contact lists and state-by-state detail are in Caduvo.
Medicare utilization for Q5130, 2023–2024
| Year | Services | Beneficiaries | Avg. allowed | Avg. paid |
|---|---|---|---|---|
| 2023 | 9,184 | 363 | $212.80 | $169.60 |
| 2024 | 69,838 | 1,617 | $192.21 | $152.94 |
States with the most Q5130 services (2024)
| State | Services | Avg. paid |
|---|---|---|
| California | 8,925 | $153.18 |
| Maryland | 5,848 | $152.01 |
| Nebraska | 5,520 | $154.03 |
| Georgia | 5,460 | $153.62 |
| Washington | 4,922 | $153.47 |
NCCI unit limits (MUE)
| Claim type | Max units per day | Rationale |
|---|---|---|
| outpatient hospital claims | 12 | Prescribing Information |
| practitioner claims | 12 | Prescribing Information |
Medicare policy articles for this code
- A56748: Billing and Coding: White Cell Colony Stimulating Factors (Palmetto GBA (MAC - Part A, MAC - Part B))
Covered diagnoses (1,265 ICD-10-CM codes)
The diagnoses most often listed as covered in the policy articles above:
| ICD-10-CM | Diagnosis | Articles listing it |
|---|---|---|
| B20 | Human immunodeficiency virus [HIV] disease | 1 |
| C00.0 | Malignant neoplasm of external upper lip | 1 |
| C00.1 | Malignant neoplasm of external lower lip | 1 |
| C00.2 | Malignant neoplasm of external lip, unspecified | 1 |
| C00.3 | Malignant neoplasm of upper lip, inner aspect | 1 |
| C00.4 | Malignant neoplasm of lower lip, inner aspect | 1 |
| C00.5 | Malignant neoplasm of lip, unspecified, inner aspect | 1 |
| C00.6 | Malignant neoplasm of commissure of lip, unspecified | 1 |
| C00.8 | Malignant neoplasm of overlapping sites of lip | 1 |
| C00.9 | Malignant neoplasm of lip, unspecified | 1 |
Showing 10 of 1,265. The full list, non-covered diagnoses and CSV export are in Caduvo.
What changed for Q5130
- 2023-04-01: Q5130 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 Q5130?
Q5130 is the HCPCS Level II code for injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg. Short descriptor: "Inj, fylnetra, 0.5 mg".
How much does Medicare pay for Q5130?
In 2024, the average Medicare payment was $152.94 per service (average allowed $192.21).
Does Medicare cover Q5130?
Coverage code C — Carrier judgment. Coverage is decided by the Medicare contractor (MAC) case by case.
Which diagnoses support coverage for Q5130?
Medicare policy articles that cite Q5130 list 1,265 covered ICD-10-CM diagnosis codes across 1 article. The most cited include B20 (Human immunodeficiency virus [HIV] disease), C00.0 (Malignant neoplasm of external upper lip), C00.1 (Malignant neoplasm of external lower lip). A listed diagnosis is necessary but not sufficient; the policy's other criteria still apply.
How many units of Q5130 can be billed per day?
12 on outpatient hospital claims; 12 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
- Q5104 — Injection, infliximab-abda, biosimilar, (renflexis), 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
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Next steps
- Run a reimbursement report for a device billed under Q5130
- Watch Q5130 for fee, coverage and descriptor changes
- Build a full Medicare revenue model for Q5130
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.