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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 J1203
5 MG
Medicare payment limit per unit (Q4 2026): $96.491
| Setting | Max units / day | Adjudication (MAI) | CMS rationale |
|---|---|---|---|
| Practitioner services (professional claims) | 630 | 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. | CMS Policy |
| Facility outpatient hospital services | 630 | 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. | CMS Policy |
| DME supplier services | 630 | 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.
Current Medicare Part B payment limit · Q4 2026
$96.491per 5 MG
Effective Oct 1, 2026 – Dec 31, 2026 · ASP methodology (per CMS file) · based on Q2 2026 ASP data · coinsurance 19.727%
CMS note: “Inflation-adjusted coinsurance”
| Quarter | Effective | Payment limit | Per (billing unit) | Coinsurance | Change | CMS notes |
|---|---|---|---|---|---|---|
| Q4 2026 | Oct 1, 2026 – Dec 31, 2026 | $96.491 | 5 MG | 19.727% | +0.2% | Inflation-adjusted coinsurance |
| Q3 2026 | Jul 1, 2026 – Sep 30, 2026 | $96.302 | 5 MG | 19.304% | +4.2% | Inflation-adjusted coinsurance |
| Q2 2026 | Apr 1, 2026 – Jun 30, 2026 | $92.398 | 5 MG | 20% | +1.3% | — |
| Q1 2026 | Jan 1, 2026 – Mar 31, 2026 | $91.203 | 5 MG |
Medicare hospital outpatient (OPPS) · Q4 2026
G Paid separately (pass-through drug or biological)
$96.491 per unit · APC 0737 · copayment $19.040 per unit
CMS note: “Inflation-adjusted coinsurance”
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.
| NDC (11-digit) | CMS drug name · labeler | Pkg size × qty | Units / item | Units / NDC | Derived $ / NDC | Crosswalk | Quarters | FDA listing |
|---|---|---|---|---|---|---|---|---|
| 71904-0200-01 | PombilitiAmicus Therapeutics US, LLC | 1 × 1 | 21 | 21 | $2,026.31 | ASP | Q2 2024 – Q4 2026 | ListedPombiliti Atga |
Derived calculation “Derived $ / NDC” = billable units per NDC × the current payment limit. It is arithmetic for orientation, not a payment amount.
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 |
|---|---|---|---|
| Q2 2024 | Added to HCPCS | A — Added | Added date Apr 1, 2024 |
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
| 20% |
| −0.0% |
| — |
| Q4 2025 | Oct 1, 2025 – Dec 31, 2025 | $91.213 | 5 MG | 20% | +1.6% | — |
|---|
| Q3 2025 | Jul 1, 2025 – Sep 30, 2025 | $89.797 | 5 MG | 20% | −0.1% | — |
|---|
| Q2 2025 | Apr 1, 2025 – Jun 30, 2025 | $89.846 | 5 MG | 20% | +0.5% | — |
|---|
| Q1 2025 | Jan 1, 2025 – Mar 31, 2025 | $89.377 | 5 MG | 20% | +1.5% | — |
|---|
| Q4 2024 | Oct 1, 2024 – Dec 31, 2024 | $88.055 | 5 MG | 20% | −0.1% | — |
|---|
| Q3 2024 | Jul 1, 2024 – Sep 30, 2024 | $88.141 | 5 MG | 20% | — | Added July 2024 |
|---|