Does J2274 require prior authorization?

No, J2274 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J2274?

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

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

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.

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.
Implantable infusion pumps and associated services are covered when used for conditions listed in the CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §280.14 (Infusion Pumps).
Implantable infusion pumps are indicated to administer medications via intra-arterial, intrathecal, or epidural routes.

L33794 — External Infusion Pumps

J19

L40247 — External Infusion Pumps

J19

AMBETTER-CP.MP.173 — Implantable Intrathecal or Epidural Pain Pump

AETNA-CPB-0725 — Post-Herpetic Neuralgia

A56695 — Billing and Coding: Implantable Infusion Pump

Ask Verity about documentation requirements, denial risks, or coverage in your state.