Summary & Overview
HCPCS J0604: Cinacalcet, Oral 1 mg (ESRD on Dialysis)
HCPCS Level II code J0604 denotes cinacalcet, oral, 1 mg, for patients with end-stage renal disease on dialysis. This national-level billing code identifies the unit dosage of an oral calcimimetic used to manage secondary hyperparathyroidism in dialysis-dependent patients, an important component of ESRD pharmacotherapy and dialysis care coordination. The code matters because medication billing for cinacalcet affects pharmacy reimbursement, medication access at dialysis centers, and cost management for payers covering renal replacement therapy.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of clinical context for cinacalcet use in ESRD on dialysis, the service setting where this code is typically applied, and what to expect in billing workflows. The publication summarizes available national benchmarks and payer coverage considerations where provided, highlights policy and coding updates affecting HCPCS Level II medication reporting, and outlines operational implications for outpatient dialysis centers and pharmacies that dispense or administer cinacalcet.
Data not available in the input for payer-specific rates, ICD-10 pairings, or associated taxonomies; this publication notes where those elements are required for claims processing.
Billing Code Overview
HCPCS Level II code J0604 represents cinacalcet, oral, 1 mg, indicated for use in patients with end-stage renal disease (ESRD) on dialysis. This billing code denotes a dosage unit of the oral calcimimetic agent cinacalcet used to manage secondary hyperparathyroidism associated with ESRD.
Service Type: Oral medication administration (pharmacy-dispensed dose)
Typical Site of Service: Outpatient dialysis center or outpatient pharmacy for patients receiving dialysis
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 58-year-old patient with end-stage renal disease (ESRD) on maintenance hemodialysis is managed in an outpatient dialysis clinic and nephrology clinic. The patient has secondary hyperparathyroidism with persistently elevated parathyroid hormone (PTH) levels and hypercalcemia or hyperphosphatemia despite phosphate binders and vitamin D analog therapy. The multidisciplinary workflow includes nephrology assessment, medication reconciliation, prescription of an oral calcimimetic agent, and education for administration and side-effect monitoring.
In the dialysis clinic, nursing documents medication administration and monitors for adverse effects such as hypocalcemia and gastrointestinal symptoms. Laboratory monitoring includes serial serum calcium, phosphorus, PTH, and routine dialysis labs. Prescription and billing use the HCPCS Level II code J0604 for cinacalcet, oral, 1 mg, dispensed for a patient with ESRD on dialysis. Prior authorization may be required by some payors. Pharmacy dispenses per the nephrologist’s order with dosing titration based on PTH and calcium results. Follow-up nephrology visits evaluate efficacy, adverse events, and need for dose adjustment or alternative therapies.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier | Standard reporting when no additional modifier applies |