Hemophilia Clotting Factor Billing


Medicare Part B covers blood clotting factors and related items used for the administration of such factors for hemophilia patients competent to use such factors without medical supervision. Hemophilia encompasses the following conditions:

  • Factor VIII deficiency (classic hemophilia);
  • Factor IX deficiency (also termed plasma thromboplastin component (PTC) or Christmas factor deficiency); and
  • Von Willebrand's disease

Part B blood clotting factors are priced as a drug/biological under the drug pricing fee schedule. A furnishing fee is paid for items and services associated with clotting factor.

NOTE: The electronic claim examples below are for PC-ACE users. Providers not using PC-ACE should contact their software vendor for claim completion assistance.

CMS-1500 Claim Example - To determine the correct units to bill per line, divide the number of units given by the Medically Unlikely Edit (MUE) Value. For example, HCPCS J7185 has a MUE Value of 4000 units per line. This is the maximum number of units which can be billed per line (as per MAI). If more than one line needs to be billed, the repeat modifier must be appended to the second and subsequent lines. Refer to the Medicare Unlikely Edits  for MUE Values.

Dollar Amount Exceeds $99,999.99 If providing a month supply and the total billed amount exceeds $99,999.99, two claims must be submitted.


Additional Important Claim Information

If required claim information is not submitted, a claim will deny as unprocessable. When a code denies as unprocessable, correct the claim error and resubmit a new claim.

If a claim denies due to the number of units exceeding acceptable maximum (e.g. N362), verify MUEs and number of allowable units. MUEs denied have appeal rights. Medical documentation must support services rendered.

Date of Service

If the Factor IIX is administered within a facility or "incident to" a physician service, enter the actual date the drug was administered as the DOS. If the Factor IIX is being billed by a pharmacy to replenish the patient's home supply, enter the date of delivery as the claim DOS.


The amount of clotting factors determined to be necessary to have on hand and thus covered under this provision is based on the historical utilization pattern or profile developed by the carrier for each patient. Changes in a patient's medical needs over a period of time may require adjustments in the profile. It is expected that the treating source, e.g., a family physician or Comprehensive Hemophilia Diagnostic and Treatment Center, will have such information.

For hemophilia factors, we would expect:

  • Diagnosis on a claim must be one of the hemophilia diagnosis codes
  • Provider's prescription must include:
    • Name of drug
    • Concentration (if applicable)
    • Dosage to include initiation date, frequency of administration, duration of infusion (if applicable), signature, date and any other individual state requirements
  • Record from physician's office must include evidence of medical necessity
  • Copy of this medical record must be provided on request


Last Updated May 03, 2017