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HCPCS J1961: Injection, Lenacapavir for HIV Treatment, 1 mg

HCPCS Level II code J1961 designates lenacapavir as an injectable agent for HIV treatment, billed per 1 mg. Lenacapavir is a long-acting antiretroviral formulation used in specialist and clinic-based settings, making the code important for practices that provide injectable HIV therapies and for payers managing specialty drug spend. Nationally, accurate coding of J1961 affects claim adjudication, specialty pharmacy billing, and access to long-acting HIV treatment options.

Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication outlines payer coverage patterns and where available, benchmark approaches to reimbursement for injectable antiretrovirals.

Readers will find concise benchmarks, clinical context for use of lenacapavir injections, and policy-related updates relevant to billing and coverage for specialty injectable HIV therapies. The report summarizes common billing considerations for clinic and infusion settings, highlights national payer approaches, and provides clarity on how J1961 is represented in service lines for outpatient administration. Data not available in the input is noted where applicable.

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Billing Code Overview

HCPCS Level II code J1961 is for injection, lenacapavir (only for use as hiv treatment), 1 mg. This code represents the drug product used specifically for the treatment of human immunodeficiency virus (HIV).

Service type: Drug administration (injectable antiviral therapy)

Typical site of service: Outpatient clinic, infusion center, or clinic-based injection setting

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HCPCS J1961: Injection, Lenacapavir for HIV Treatment, 1 mg

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Get alerted when payer policies referencing J1961 are released or updated.

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Billing Code Overview

Service type: Drug administration (injectable antiviral therapy)

Typical site of service: Outpatient clinic, infusion center, or clinic-based injection setting

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult with multidrug-resistant HIV-1 infection receiving long-acting injectable antiretroviral therapy. The medication J1961 (lenacapavir, 1 mg units) is administered by a trained clinician in an outpatient infusion clinic, HIV clinic, or specialty pharmacy clinic. The workflow includes medication reconciliation, confirmation of current antiretroviral regimen and resistance profile, verification of dosing schedule (induction subcutaneous or maintenance subcutaneous every two months as clinically indicated), informed consent for injection therapy, medication preparation and dose calculation (multiple milligrams per dose using J1961 units), subcutaneous injection in the abdomen or buttock, monitoring for immediate adverse reactions for 15–30 minutes, documentation of lot number and units billed, and scheduling of the next administration. Typical sites of service are outpatient infusion center, physician office, or ambulatory clinic. Patient counseling covers injection site reactions, signs of hypersensitivity, adherence to concurrent oral antiretrovirals if required, and instructions to contact their HIV care team for systemic symptoms.

Coding Specifications

Modifier	Description	When to Use
`00`	No modifier — standard reporting	Use when no special circumstance modifier applies to the service.
`22`	Increased procedural services	Use if unusually complex preparation or extended time for administration beyond typical lenacapavir injection.
`23`	Unusual anesthesia	Rarely used; only if unexpected anesthesia is required for the injection.
`52`	Reduced services	Use when a reduced dose or partial administration occurs.
`59`	Distinct procedural service	Use when billing a separate distinct injection service on the same date as another unrelated procedure.
`62`	Two surgeons	Use only if two providers of different specialties both perform services that meet payment rules for shared operative care (rare for injections).
`78`	Return to OR for related procedure following initial procedure	Not typical; use only if patient requires a related surgical return after complications.
`80`	Assistant at surgery	Use if an assistant surgeon is present and billable for a related surgical service.
`JW`	Drug discarded/waste	Use to report discarded portion of single-dose vial when billing for the administered amount.
`JZ`	No drug wastage	Use to indicate there was no waste of a single-dose vial.
`QX`	Certified nurse practitioner	Use when service is performed by a nurse practitioner reporting their billing under their NPI as permitted.
`QY`	Physician assistant	Use when the service is performed by a physician assistant under applicable billing rules.
`SH`	Speech-language pathology assistant	Not applicable to this service; listed only if a practice’s modifier set requires it.
`TG`	Monoclonal antibody administration	Use when reporting administration of monoclonal antibody agents when payer-specific guidance maps this modifier to specialty drug administration; apply only if payer requires.

Taxonomy Code	Specialty	Notes
`207RG0100X`	Infectious Disease	Primary specialty prescribing and overseeing long-acting HIV therapy.
`208000000X`	Internal Medicine	Primary care physicians managing HIV patients and coordinating injections in clinic.
`363LP0800X`	Clinical Pharmacology	Clinical pharmacists involved in dosing, preparation, and medication counseling.
`164W00000X`	Nurse Practitioner	Advanced practice providers who may perform administration and follow-up.
`174400000X`	Physician Assistant	Mid-level providers who may perform administration and documentation.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`B20`	Human immunodeficiency virus [HIV] disease	Primary diagnosis indicating HIV infection requiring antiretroviral therapy, the chief indication for lenacapavir.
`Z21`	Asymptomatic human immunodeficiency virus [HIV] infection status	Used when patient is HIV-positive without symptomatic disease but receives antiretroviral therapy.
`B97.35`	Human immunodeficiency virus 1 [HIV-1]	Specific etiologic code for HIV-1 infection relevant for therapeutic decisions.
`R75`	Inconclusive laboratory evidence of human immunodeficiency virus [HIV]	May be used in workups where initial testing is indeterminate and therapy decisions are in progress.
`Z79.899`	Other long term (current) drug therapy	Use to indicate the patient is on chronic antiretroviral medication therapy including long-acting agents.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`96372`	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular	Commonly used to report the act of administering a subcutaneous injection of lenacapavir when payer allows a separate administration code along with the drug HCPCS `J1961`.
`96401`	Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic	Occasionally used by some practices for complex specialty drug administration workflows when appropriate by payer rules.
`36415`	Collection of venous blood by venipuncture	Performed prior to injection for baseline viral load, resistance testing, or safety labs.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Used for routine follow-up or evaluation visit associated with drug administration and counseling.
`99070`	Supplies and materials provided by the physician over and above those usually included with the service	Used to bill clinic-provided supplies associated with injection preparation when payer permits separate supply billing.

Related Codes

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

HCPCS Level II J0013: Esketamine Nasal Spray, 1 mg

HCPCS-J0120-INJECTION-TETRACYCLINE-250MG

HCPCS J0120: Injection, Tetracycline, Up to 250 mg

HCPCS-J0121-OMADACYCLINE-INJECTION-1MG

HCPCS J0121: Omadacycline Injection, 1 mg

HCPCS-J0122-ERAVACYCLINE-INJECTION-1MG

HCPCS J0122: Injection, Eravacycline, 1 mg

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

HCPCS 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 J0131: Injection Acetaminophen, 10 mg

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

HCPCS J0132: Injection, Acetylcysteine 100 mg

HCPCS-J0133-ACYCLOVIR-INJECTION-5MG

HCPCS J0133: Injection, Acyclovir 5 mg

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

HCPCS J0134: Injection, Acetaminophen (Fresenius Kabi), 10 mg

Showing 1–10 of 991

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Modifier	Description	When to Use
`00`	No modifier — standard reporting	Use when no special circumstance modifier applies to the service.
`22`	Increased procedural services	Use if unusually complex preparation or extended time for administration beyond typical lenacapavir injection.
`23`	Unusual anesthesia	Rarely used; only if unexpected anesthesia is required for the injection.
`52`	Reduced services	Use when a reduced dose or partial administration occurs.
`59`	Distinct procedural service	Use when billing a separate distinct injection service on the same date as another unrelated procedure.
`62`	Two surgeons	Use only if two providers of different specialties both perform services that meet payment rules for shared operative care (rare for injections).
`78`	Return to OR for related procedure following initial procedure	Not typical; use only if patient requires a related surgical return after complications.
`80`	Assistant at surgery	Use if an assistant surgeon is present and billable for a related surgical service.
`JW`	Drug discarded/waste	Use to report discarded portion of single-dose vial when billing for the administered amount.
`JZ`	No drug wastage	Use to indicate there was no waste of a single-dose vial.
`QX`	Certified nurse practitioner	Use when service is performed by a nurse practitioner reporting their billing under their NPI as permitted.
`QY`	Physician assistant	Use when the service is performed by a physician assistant under applicable billing rules.
`SH`	Speech-language pathology assistant	Not applicable to this service; listed only if a practice’s modifier set requires it.
`TG`	Monoclonal antibody administration	Use when reporting administration of monoclonal antibody agents when payer-specific guidance maps this modifier to specialty drug administration; apply only if payer requires.

Taxonomy Code	Specialty	Notes
`207RG0100X`	Infectious Disease	Primary specialty prescribing and overseeing long-acting HIV therapy.
`208000000X`	Internal Medicine	Primary care physicians managing HIV patients and coordinating injections in clinic.
`363LP0800X`	Clinical Pharmacology	Clinical pharmacists involved in dosing, preparation, and medication counseling.
`164W00000X`	Nurse Practitioner	Advanced practice providers who may perform administration and follow-up.
`174400000X`	Physician Assistant	Mid-level providers who may perform administration and documentation.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`B20`	Human immunodeficiency virus [HIV] disease	Primary diagnosis indicating HIV infection requiring antiretroviral therapy, the chief indication for lenacapavir.
`Z21`	Asymptomatic human immunodeficiency virus [HIV] infection status	Used when patient is HIV-positive without symptomatic disease but receives antiretroviral therapy.
`B97.35`	Human immunodeficiency virus 1 [HIV-1]	Specific etiologic code for HIV-1 infection relevant for therapeutic decisions.
`R75`	Inconclusive laboratory evidence of human immunodeficiency virus [HIV]	May be used in workups where initial testing is indeterminate and therapy decisions are in progress.
`Z79.899`	Other long term (current) drug therapy	Use to indicate the patient is on chronic antiretroviral medication therapy including long-acting agents.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`96372`	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular	Commonly used to report the act of administering a subcutaneous injection of lenacapavir when payer allows a separate administration code along with the drug HCPCS `J1961`.
`96401`	Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic	Occasionally used by some practices for complex specialty drug administration workflows when appropriate by payer rules.
`36415`	Collection of venous blood by venipuncture	Performed prior to injection for baseline viral load, resistance testing, or safety labs.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Used for routine follow-up or evaluation visit associated with drug administration and counseling.
`99070`	Supplies and materials provided by the physician over and above those usually included with the service	Used to bill clinic-provided supplies associated with injection preparation when payer permits separate supply billing.

Related Codes

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

HCPCS Level II J0013: Esketamine Nasal Spray, 1 mg

HCPCS-J0120-INJECTION-TETRACYCLINE-250MG

HCPCS J0120: Injection, Tetracycline, Up to 250 mg

HCPCS-J0121-OMADACYCLINE-INJECTION-1MG

HCPCS J0121: Omadacycline Injection, 1 mg

HCPCS-J0122-ERAVACYCLINE-INJECTION-1MG

HCPCS J0122: Injection, Eravacycline, 1 mg

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

HCPCS 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 J0131: Injection Acetaminophen, 10 mg

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

HCPCS J0132: Injection, Acetylcysteine 100 mg

HCPCS-J0133-ACYCLOVIR-INJECTION-5MG

HCPCS J0133: Injection, Acyclovir 5 mg

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

HCPCS J0134: Injection, Acetaminophen (Fresenius Kabi), 10 mg

Showing 1–10 of 991

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

OpenPayer

HCPCS J1961: Injection, Lenacapavir for HIV Treatment, 1 mg

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Billing Code Overview

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HCPCS J1961: Injection, Lenacapavir for HIV Treatment, 1 mg

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Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References