Summary & Overview
HCPCS J2406: Oritavancin (Kimyrsa) Injection, 10 mg
HCPCS Level II code J2406 denotes a 10 mg unit of oritavancin (brand name Kimyrsa), an intravenous agent used in the management of serious bacterial infections. As a drug-specific HCPCS Level II code, J2406 is used on medical claims to report administration of kimyrsa in infusion-capable settings and to enable payer reimbursement and utilization tracking. Nationally, consistent coding for high-cost antimicrobials like oritavancin is important for payment accuracy, utilization monitoring, and formulary management.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of how the code is used in clinical and billing workflows, typical sites of service for administration, and the types of benchmarks and policy issues that commonly accompany drug-specific HCPCS codes. The piece highlights common payer considerations such as prior authorization, billing units, and claim adjudication patterns for injectable specialty drugs.
This report provides national context on coding practice, payer coverage landscape, and clinical setting implications for J2406. It is intended to aid billing professionals, pharmacy directors, and revenue cycle stakeholders in understanding the role of this HCPCS Level II code in medical claims and payer interactions.
Billing Code Overview
HCPCS Level II code J2406 represents Injection, oritavancin (kimyrsa), 10 mg. The service is an intravenous antibiotic administration for a single 10 mg unit of oritavancin packaged as kimyrsa. Typical site of service for this injectable medication is hospital outpatient infusion centers or ambulatory infusion clinics, though administration may also occur in other infusion-capable clinical settings.
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Clinical & Coding Specifications
Clinical Context
A 62-year-old male with a history of type 2 diabetes and peripheral vascular disease presents to the outpatient infusion clinic with a complicated skin and soft tissue infection (cSSTI) of the lower extremity diagnosed after failed oral therapy and progressive cellulitis with surrounding induration and purulent drainage. Culture and susceptibility data indicate an organism susceptible to oritavancin. The treating infectious disease physician orders a single-dose intravenous administration of J2406 (oritavancin, 10 mg vial) prepared and administered by trained infusion nursing staff.
The clinical workflow includes: initial evaluation and documentation of diagnosis and indication in the electronic medical record; verification of medication orders and weight-based dosing considerations; pharmacy preparation under aseptic technique; infusion nurse assessment for allergies and venous access; administration per product labeling with appropriate infusion time and monitoring for infusion-related reactions; observation period post-infusion for hypersensitivity; documentation of lot number and expiration on the medication administration record; and submission of the HCPCS code J2406 with applicable modifier(s) and the primary ICD-10 diagnosis on the claim. Typical sites of service include outpatient infusion centers, hospital outpatient departments, and emergency departments requiring intravenous antibiotics when hospitalization is not indicated.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|