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    v1.0.30
    OpenPayerBilling CodesDrugs Administered Other than Oral MethodHCPCS hcpcs-j1428-eteplirsen-injection-10mg
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    HCPCS Level II J1428: Injection, eteplirsen, 10 mg

    HCPCS Level II code J1428 describes an injection of eteplirsen, 10 mg, used as an intravenous or intramuscular therapeutic infusion for patients requiring exon-skipping therapy; the service type is drug administration and the typical site of service is an outpatient infusion clinic or hospital outpatient department where specialty biologic therapies are delivered.

    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 typical patient is a male child or young adult with Duchenne muscular dystrophy (DMD) caused by a confirmed mutation amenable to exon 51 skipping. The patient presents to a specialty neuromuscular clinic or infusion center for scheduled intravenous administration of eteplirsen. The clinical workflow includes medication verification and insurance authorization, baseline vital signs and assessment of weight and infusion access, preparation of J1428 (eteplirsen, 10 mg) by pharmacy under sterile technique, administration via IV infusion with monitoring for infusion reactions, documentation of lot number and dose administered, and post-infusion observation before discharge. Visits typically occur in an outpatient hospital infusion center, ambulatory infusion clinic, or specialty physician office with infusion capability. Coordination involves the neuromuscular specialist, infusion nurse, clinical pharmacist, and billing staff to apply appropriate modifiers and diagnosis linkage for reimbursement with payors such as Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    96365Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hourCommonly billed for the initial infusion time associated with IV-administered eteplirsen when infusion duration fits the code definition
    96366Intravenous infusion, each additional hourUsed if the eteplirsen infusion extends beyond the initial hour and requires additional infusion time billing
    96413Chemotherapy administration, IV infusion technique; up to 1 hour, single or initial substance/drugOccasionally used in oncology-style infusion workflows; facility and payor guidance determine appropriateness vs 96365
    99213Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutesUsed for routine follow-up or evaluation visit tied to ongoing eteplirsen therapy when an E/M service is provided on the same day
    93000Electrocardiogram, routine ECG with interpretation and reportPerformed periodically in some DMD protocols to monitor cardiac status before or after therapy
    94640Pressurized or non-pressurized inhalation treatment for acute airway obstructionExample supportive therapy code that may be used if respiratory treatment is provided during an infusion encounter

    Related Modifiers

    8 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…
    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
    2084P0800X
    207RC0000X
    364S00000X
    3336C0002X
    207L00000X
    2080A0000X
    2083S0010X
    207XS0114X

    Related ICD-10-CM Codes

    26 rows

    ICD-10-CM CodeDescription
    E70.0Classical phenylketonuria
    E88.9Metabolic disorder, unspecified
    F80.2Mixed receptive-expressive language disorder
    F82Specific developmental disorder of motor function
    G12.20Motor neuron disease, unspecified
    G12.21Amyotrophic lateral sclerosis
    G12.22Progressive bulbar palsy
    G71.01Duchenne or Becker muscular dystrophy
    G71.09Other specified muscular dystrophies
    G71.11Myotonic muscular dystrophy

    Showing 1–10 of 26

    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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