Does J2278 require prior authorization?

No, J2278 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J2278?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J2278`, Injection, ziconotide, 1 microgram

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

When billing J7999-KD, enter the name and total dose (mg or mcg) of each drug in Box 19 of the CMS-1500 or the appropriate electronic comment loop; if Box 19 cannot accommodate all information, attach the details to the paper claim.
If a portion of a single-dose vial is not used, submit the HCPCS code for the drug on a separate claim line and append modifier JW to indicate discarded/unused portion.

Separate payment may be made for pump refilling and/or adjustments; submit these services using the appropriate drug refill or maintenance CPT/HCPCS code that accurately describes the service rendered.

Compounded drugs are priced by the A/B MAC contractor by multiplying the contractor's price per mcg or mg by the total number of mcg or mg of each drug used; a pharmacy compounding fee may be allowed in addition to the calculated drug amount.

Use the listed CPT/HCPCS codes when billing for opioid drugs or procedures related to implantable pumps for chronic intractable pain: J7999-KD, E0782, E0783, E0785, E0786, J2274 (example), J2278-KD, 62327, 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 62369, 62370, 95990, 95991.

Key Coverage Criteria

Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.
True off-the-shelf (non‑compounded) drugs used without compounding and administered via DME may be billed using the drug-specific HCPCS code and are reimbursed under CMS ASP methodology.
If Prialt® is implanted as a single agent in the pump, bill using HCPCS code J2278-KD.
Compounded single-agent or combination drug formulations used in implanted infusion pumps must be billed using HCPCS code J7999-KD for reimbursement.
External infusion pumps (HCPCS E0779, E0780, E0781, E0791) are covered for administration of deferoxamine for treatment of chronic iron overload.
External infusion pumps are covered for administration of anticancer chemotherapy for unresectable primary hepatocellular carcinoma or unresectable colorectal cancer or when the beneficiary refuses surgical excision of the tumor.

5 Active Policies

PALMETTO-JJ-L33461, Implantable Infusion Pump

PALMETTO-JM-L33461, Implantable Infusion Pump

A56695, Billing and Coding: Implantable Infusion Pump

L33794, External Infusion Pumps

AETNA-CPB-0712, Ziconotide (Prialt)

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J2278, Injection, ziconotide, 1 microgram