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Descriptors and administrative fields exactly as published in the CMS HCPCS quarterly file.
Billing context: J-codes
Units are reported in multiples of the dosage in the code descriptor.
One HCPCS billing unit of J0207
500 MG
| Setting | Max units / day | Adjudication (MAI) | CMS rationale |
|---|---|---|---|
| Practitioner services (professional claims) | 4 | 3 Date of Service Edit: ClinicalDate-of-service edit (clinical benchmarks): more units for the same patient and date are possible but medically highly unlikely; documentation of medical necessity may be considered. | Clinical: Data |
| Facility outpatient hospital services | 4 | 3 Date of Service Edit: ClinicalDate-of-service edit (clinical benchmarks): more units for the same patient and date are possible but medically highly unlikely; documentation of medical necessity may be considered. | Clinical: Data |
| DME supplier services | 0Not reportable in this setting | 3 Date of Service Edit: ClinicalDate-of-service edit (clinical benchmarks): more units for the same patient and date are possible but medically highly unlikely; documentation of medical necessity may be considered. |
Medicare Part B drug payment limits per billing unit, by quarter, from the CMS payment limit (ASP) files.
Most recent Medicare Part B payment limit · Q1 2021
$1,135.691per 500 MG
Effective Jan 1, 2021 – Mar 31, 2021 · ASP methodology (per CMS file) · based on Q3 2020 ASP data
Not in the latest payment limit file (Q4 2026). Shown for history only.
| Quarter | Effective | Payment limit | Per (billing unit) | Coinsurance | Change | CMS notes |
|---|---|---|---|---|---|---|
| Q1 2021 | Jan 1, 2021 – Mar 31, 2021 | $1,135.691 | 500 MG | — | — | — |
Medicare hospital outpatient (OPPS) · Q4 2026
E1 Not covered by Medicare
Washington Apple Health · professional claims
AAC = actual acquisition cost, based on NDC or invoice; BR = by report; NC = not covered; DC = not covered, see a different code; DP = covered under another program (see comments); PA = prior authorization; EPA = expedited prior authorization (see the billing guide); CPA = contractor prior authorization (Qualis). For professional claims; hospital-administered drugs are paid under HCA's outpatient (OPPS/EAPG) rules.
Packages CMS assigns to this code in its NDC–HCPCS crosswalks, with billable units per package. Only official crosswalk rows are shown.
No CMS NDC–HCPCS crosswalk rows were located. CMS notes its crosswalks are not a comprehensive list of all NDCs.
| NDC (11-digit) | CMS drug name · labeler | Pkg size × qty | Units / item | Units / NDC | Crosswalk | Quarters | FDA listing |
|---|---|---|---|---|---|---|---|
| 66220-0017-03 | EthyolCUMBERLAND PHARMACEUTICALS | 1 × 3 | 1 | 3 | OPPS | Q1 2021 – Q4 2022Not in Q4 2026 file | Excluded listingEthyol |
Medicare coverage is set nationally (NCDs) and by each Medicare Administrative Contractor (LCDs and Billing & Coding articles). These links open the official documents.
Verification neededCodeRx links to coverage documents instead of copying them: CMS distributes their code lists under AMA, ADA, and AHA license terms that limit reuse. Medicare Advantage, Medicaid, and commercial plans set their own coverage and prior-authorization rules.
Changes detected between the CMS quarterly HCPCS files CodeRx has imported.
| Quarterly file | Change | CMS action code | Details |
|---|---|---|---|
| Q1 2023 | In earliest ingested file | P — Payment change | Added date Jan 1, 1998 |
All imported releases, checksums, and import reports are listed on the data sources page.
Disclaimer. This application provides informational coding and reimbursement reference data. It does not constitute legal, clinical, coding, or billing advice. Codes, payment amounts, payer rules, and coverage policies can change. Verify all information with current CMS publications, the applicable payer, and your organization’s compliance policies before submitting a claim. CodeRx is not affiliated with or endorsed by CMS, FDA, Medicare, or any payer.
| CMS Policy |
An MUE is the most units CMS expects for this code for one patient on one date of service by the same provider in most correctly reported claims. CMS MUE program