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    v1.0.31
    OpenPayerBilling CodesDrugs Administered Other than Oral MethodHCPCS hcpcs-j0638-canakinumab-injection-1mg
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    HCPCS Level II J0638: Canakinumab Injection, 1 mg

    HCPCS Level II code J0638 describes an injectable biologic product, canakinumab, billed per 1 mg unit for administration as a subcutaneous or intravenous medication; the service is the injection of canakinumab typically provided in outpatient infusion centers, physician offices, or specialty clinics for conditions treated with this interleukin‑1β inhibitor.

    For related coverage guidance, see recent payer policy updates: Bendamustine Products Coverage Criteria, T-Cell Lymphoma Agents: Beleodaq, Istodax, Lymphir, Poteligeo, and Romidepsin, Brentuximab Vedotin (Adcetris®) Coverage Criteria.

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    Clinical & Coding Specifications

    Clinical Context

    A typical patient is an adult with a documented autoinflammatory condition such as familial Mediterranean fever or periodic fever syndromes, or a patient with refractory gout or adult-onset Still disease, requiring targeted interleukin-1 beta inhibition. The medication J0638 (canakinumab, 1 mg per unit) is provided as a subcutaneous injection prepared by clinic nursing staff from vials or prefilled syringes and administered in an outpatient infusion/injection suite, specialty clinic, or physician office. The clinical workflow includes verification of indication and prior authorization, documentation of baseline vitals and review for active infection, preparation of the correct dose based on weight or protocol, administration by a licensed nurse, observation for immediate adverse reactions (typically 15–60 minutes depending on patient risk), and documentation of lot number, dose, route, site, and any patient counseling. Billing for J0638 is per milligram units; the number of units reported must match the exact milligrams administered. Typical payors include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare, each following their medical necessity and coverage policies for biologic agents.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    96372Therapeutic, prophylactic, or diagnostic injection (subcutaneous or intramuscular); single or initial substance/drugCommonly used to report the administration service for a subcutaneous canakinumab injection when separate from the drug J-code
    96365Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hourUsed if an IV infusion is required for administration or observation in unusual circumstances
    36415Collection of venous blood by venipunctureOften performed prior to biologic dosing for baseline labs such as CBC or inflammatory markers
    97034Apply/continue hot/cold packs (not commonly used)Not typically related but included only if ancillary supportive services are provided during the visit
    99070Supplies and materials, administrative, not covered by basic serviceUse for special supplies associated with drug administration when payor allows separate supply billing

    Related Modifiers

    5 rows

    ModifierDescriptionWhen to Use
    78CPT modifier -78 indicates an unplanned, related return to the operating or procedure room by the same provider during the global postoperative period. It is appended when treatment for a…- Use modifier -78 when an unplanned, related complication during the original procedure’s global postoperative period requires the patient to return to a formal operating or procedure room and the…
    80CPT® Modifier 80 (Assistant Surgeon) is appended to a surgical CPT code when a physician (MD or DO) provides full, continuous assistance throughout the operative procedure. It is intended only for…- Use CPT Modifier -80 when a physician (MD or DO) serves as an assistant surgeon and provides full, continuous assistance throughout the entire operative procedure; append -80 to the surgical CPT…
    82Modifier 82 is appended to a surgical CPT code to indicate that an attending physician acted as an assistant because a qualified resident surgeon was unavailable. In teaching hospitals it documents…- When to use: Append modifier 82 in teaching-hospital settings to indicate a physician served as an assistant surgeon because a qualified resident surgeon was unavailable (includes situations where…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207RC0000X
    208000000X
    363L00000X
    367500000X
    1744P3200X
    261QR0405X
    364SP0810X
    335V00000X

    Related Payer Policy Updates

    Specialty: Hematology/Oncology1 / 3

    10 rows

    PolicyPayerEffective Date
    Bendamustine Products Coverage Criteriablue cross blue shield - tennessee2027-01-30
    T-Cell Lymphoma Agents: Beleodaq, Istodax, Lymphir, Poteligeo, and RomidepsinMass General Brigham Health Plan2027-01-04
    Brentuximab Vedotin (Adcetris®) Coverage Criteriablue cross blue shield - tennessee2026-12-31
    Pemetrexed Coverageblue cross blue shield - tennessee2026-12-31
    Tumor Treatment Fields - Medical PolicyHealth-New-England2026-12-01
    Extracorporeal PhotopheresisCigna2026-11-15
    VonvendiCigna2026-11-15
    Hematology - AphexdaCigna2026-11-15
    Extracorporeal PhotopheresisCigna2026-11-15
    Yartemlea (narsoplimab-wuug) Coverage for TA-TMANeighborhood Health Plan of Rhode Island2026-11-01

    Related Codes

    HCPCS-J0013-ESKETAMINE-NASAL-SPRAY-1MG

    HCPCS Level II J0013: Esketamine Nasal Spray, 1 mg

    HCPCS-J0120-INJECTION-TETRACYCLINE-250MG

    HCPCS Level II J0120: Injection, Tetracycline, up to 250 mg

    HCPCS-J0121-OMADACYCLINE-INJECTION-1MG

    HCPCS Level II J0121: Omadacycline Injection, 1 mg

    HCPCS-J0122-ERAVACYCLINE-INJECTION-1MG

    HCPCS Level II J0122: Injection, eravacycline, 1 mg

    HCPCS-J0129-ABATACEPT-INJECTION-10MG-PHYSICIAN-SUPERVISED

    HCPCS Level II J0129: Abatacept Injection, 10 mg

    HCPCS-J0130-INJECTION-ABCIXIMAB-10MG

    HCPCS Level II J0130: Injection abciximab, 10 mg

    HCPCS-J0131-INJECTION-ACETAMINOPHEN-10MG-PARENTERAL-ANALGESIC

    HCPCS Level II J0131: Injection, Acetaminophen 10 mg

    HCPCS-J0132-INJECTION-ACETYLCYSTEINE-100MG-INJECTABLE-MEDICATION

    HCPCS Level II J0132: Injection, Acetylcysteine 100 mg

    HCPCS-J0133-ACYCLOVIR-INJECTION-5MG

    HCPCS Level II J0133: Injection, Acyclovir 5 mg

    HCPCS-J0134-ACETAMINOPHEN-INJECTION-FRESENIUS-KABI-10MG

    HCPCS Level II J0134: Injection, Acetaminophen (10 mg)

    Showing 1–10 of 991

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    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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