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    v1.0.30
    OpenPayerBilling CodesDrugs Administered Other than Oral MethodHCPCS hcpcs-j0738-lenacapavir-injection-hiv-pre-exposure-prophylaxis
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    HCPCS Level II J0738: Lenacapavir Injection for HIV Pre‑Exposure Prophylaxis

    HCPCS Level II code J0738 represents the billed injectable medication lenacapavir, described as a 1 mg FDA‑approved prescription for HIV pre-exposure prophylaxis (PrEP) and explicitly not for HIV treatment; the service is a pharmacologic prophylaxis injection typically administered in outpatient clinics, specialty infusion centers, or physician offices as a single‑agent injectable preventive therapy for individuals at risk of HIV exposure.

    For related coverage guidance, see recent payer policy updates: T-Cell Lymphoma Agents: Beleodaq, Istodax, Lymphir, Poteligeo, and Romidepsin, Tumor Treatment Fields - Medical Policy, Extracorporeal Photopheresis.

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    Clinical & Coding Specifications

    Clinical Context

    A 30-year-old cisgender man presents to an outpatient HIV prevention clinic seeking pre-exposure prophylaxis (PrEP) after reporting sexual exposure to partners with unknown HIV status and inconsistent condom use. Baseline evaluation includes HIV antigen/antibody testing, renal function, hepatitis B and C screening, and risk assessment. The clinician determines lenacapavir injectable PrEP is appropriate per eligibility criteria. The patient receives an initial subcutaneous or intramuscular administration of J0738 (lenacapavir) in the clinic. The clinic documents informed consent, verifies no active HIV infection, records lot number and expiration of the drug, and observes the patient for immediate adverse reactions for the standard monitoring period. Follow-up visits include interval HIV testing, assessment of adherence and side effects, and subsequent maintenance dosing per FDA-approved schedule. Typical sites of service are outpatient ambulatory clinics, community health centers, sexual health clinics, and federally qualified health centers. Billing occurs for the drug using J0738 with any applicable modifiers to reflect payer requirements, administration circumstances, or special payment situations.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    96372Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscularCommonly used for billing the administration service when separate from the drug acquisition code J0738.
    36415Collection of venous blood by venipuncturePerformed for baseline and follow-up HIV and laboratory monitoring related to PrEP.
    87807Infectious agent antigen detection by immunoassay with direct optical observation; HIV-1/2 antigen/antibodyUsed for point-of-care or laboratory HIV testing prior to and during PrEP.
    99401Preventive medicine counseling or risk-reduction intervention(s) (15 minutes)Counseling and risk-reduction services associated with initiating PrEP and adherence support.
    99213Office or other outpatient visit for the evaluation and management of an established patient, low to moderate complexityTypical E/M visit code for follow-up assessments and documentation when combined with injection services.

    Related Modifiers

    9 rows

    ModifierDescriptionWhen to Use
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    23Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
    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…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    55Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
    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…
    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…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    163W00000X
    207Q00000X
    207R00000X
    170100000X
    202K00000X
    227900000X
    225XP0019X
    156FX1100X

    Related ICD-10-CM Codes

    24 rows

    ICD-10-CM CodeDescription
    A60.9Anogenital herpesviral infection, unspecified
    F18.10Inhalant abuse, uncomplicated
    F41.9Anxiety disorder, unspecified
    F52.21Male erectile disorder
    F52.22Female sexual arousal disorder
    R45.2Unhappiness
    R45.81Low self-esteem
    R46.89Other symptoms and signs involving appearance and behavior
    Z00.129Encounter for routine child health examination without abnormal findings
    Z00.8Encounter for other general examination

    Showing 1–10 of 24

    Related Payer Policy Updates

    Specialty: Hematology/Oncology1 / 3

    10 rows

    PolicyPayerEffective Date
    T-Cell Lymphoma Agents: Beleodaq, Istodax, Lymphir, Poteligeo, and RomidepsinMass General Brigham Health Plan2027-01-04
    Tumor Treatment Fields - Medical PolicyHealth-New-England2026-12-01
    Extracorporeal PhotopheresisCigna2026-11-15
    Electric Tumor Treatment Field Therapy (for Tennessee Only)Colorado Rocky Mountain Health Plans2026-11-01
    Tumor Treating Fields Therapypremerabluecrossofwashington2026-11-01
    Tumor Treating Fields Therapypremerabluecrossofwashington2026-11-01
    OmisirgeCigna2026-11-01
    Hematology - AdzynmaCigna2026-10-15
    Transcatheter Arterial Chemoembolization for Liver Tumorspremerabluecrossofwashington2026-10-01
    Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bonepremerabluecrossofwashington2026-10-01

    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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