Summary & Overview

HCPCS J9249: Melphalan (Apotex) Injection, 1 mg

HCPCS Level II code J9249 identifies the drug product melphalan (Apotex) billed per 1 mg for use as an antineoplastic agent. As a chemotherapy drug code, J9249 is important for accurate drug acquisition cost reporting, outpatient infusion billing, and facility reimbursement for cytotoxic therapies provided in ambulatory settings. Nationally, consistent coding of single-agent chemotherapy supports claims adjudication, utilization tracking, and price transparency for high-cost oncology drugs.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find practical information on how J9249 is used in billing lines for outpatient chemotherapy encounters, typical sites of service where the code appears, and which stakeholders commonly manage coverage and prior authorization for off-label or limited-indication uses. The publication outlines benchmarks and policy context relevant to drug-specific HCPCS reporting, highlights billing considerations tied to per-milligram drug codes, and summarizes areas where readers should verify payer-specific requirements. Data not available in the input are noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareJ9249HCPCS Level IIchemotherapymelphalaninfusiononcologydrug-codingoutpatient-clinicpharmacy-billing

Billing Code Overview

HCPCS Level II code J9249 represents an injectable formulation of melphalan (Apotex), 1 mg. This code describes a chemotherapy agent supplied for intravenous administration and is used to bill for the drug product per milligram.

Service type: Chemotherapy / antineoplastic drug administration

Typical site of service: Hospital outpatient infusion center, outpatient oncology clinic, or ambulatory infusion center

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult receiving intravenous chemotherapy for a hematologic malignancy or select solid tumors where melphalan is indicated. The medication J9249 represents melphalan (Apotex) dosed per milligram; administration is most commonly performed in an outpatient infusion center, hospital outpatient department, or oncology clinic. A plausible scenario: a 62-year-old patient with multiple myeloma or myeloablative conditioning prior to autologous stem cell transplant presents for scheduled chemotherapy. The oncology nurse verifies identity, allergies, recent labs (CBC, renal function), venous access (peripheral IV or central venous catheter), and chemotherapy consent. Pharmacy compounds the dose of melphalan labeled in milligrams; the medication is administered intravenously over the protocol-specified infusion time with appropriate premedication and monitoring for infusion reactions. Documentation includes medication name, units billed as milligrams, lot number, route, site of service, start and stop times, patient tolerance, and any modifier(s) applied for billing. Typical site of service: outpatient infusion center, hospital outpatient department, or ambulatory infusion clinic.

Coding Specifications

Modifier	Description	When to Use
`JW`	Drug amount discarded/not administered	Use when a portion of the single-use vial of melphalan is discarded and the discarded amount must be reported for billing/recordkeeping when payer requires.
`QX`	Services furnished by a practitioner who is a physician’s assistant with a collaborating physician	Use when a physician assistant administers or supervises the infusion under applicable state law and the payer requires modifier reporting.
`QY`	Service performed by a registered nurse practitioner or physician assistant with Medicare-required certification of supervision	Use when required by payer to indicate services furnished by an NP/PA under a supervising physician’s plan of care.
`52`	Reduced services	Use when a planned full dose or full service is reduced (for example dose reduced per toxicity or shortened infusion) and billed amount reflects less than standard service.
`53`	Discontinued procedure	Use when the infusion is started but discontinued due to an acute adverse event and the procedure is terminated.
`22`	Increased procedural services	Use when significantly greater work or resources are required (for example prolonged monitoring for severe infusion reaction) and documentation supports extra work.
`23`	Unusual anesthesia	Not commonly applicable for standard melphalan IV infusion; use only if unusual anesthesia is required and payer accepts this modifier.
`62`	Two surgeons	Rare for chemotherapy administration; use only if two qualified practitioners are required for safety or procedures performed concurrently.
`80`	Assistant surgeon	Rare for infusion; use if an assistant surgeon was required for a concurrent procedure during the same encounter and payer rules permit.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for Medicare billing	Use when the service is furnished by one of these practitioners and payer requires identification.
`QK`	Medical direction of two to four concurrent anesthesia procedures	Not typically applicable; include only if anesthesia services meet the definition.
`FY`	Clinical trial participation	Use when melphalan is administered as part of a qualifying clinical trial and payer requires the trial participation modifier.
`SH`	Office or other outpatient service facility charges (distinct)	Use when billing facility-specific modifiers per payer for outpatient infusion facility.

Taxonomy Code	Specialty	Notes
`207P00000X`	Hematology & Oncology	Medical oncologists and hematologist-oncologists prescribe and oversee melphalan therapy.
`363A00000X`	Medical Oncology	Oncology specialists who manage systemic chemotherapy regimens and infusion protocols.
`163W00000X`	Ambulatory Infusion Center	Infusion center providers and administrators overseeing outpatient chemotherapy delivery.
`208D00000X`	Internal Medicine	Hospitalists or internists who may manage inpatient chemotherapy or supportive care.
`1744P0800X`	Nurse Practitioner	Advanced practice providers who frequently administer or supervise chemotherapy in outpatient settings.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C90.00`	Multiple myeloma not having achieved remission	Melphalan is used in treatment regimens for multiple myeloma, including conditioning prior to stem cell transplant.
`C90.02`	Multiple myeloma in relapse	Melphalan may be used in relapsed disease as part of salvage regimens.
`C83.30`	Diffuse large B-cell lymphoma, not specified as extranodal or solid organ	Melphalan can be used in select lymphoma conditioning regimens or combination therapies in certain protocols.
`C84.40`	Mycosis fungoides, unspecified	Alkylating agents including melphalan are sometimes used in cutaneous T-cell lymphomas in specific circumstances.
`D47.2`	Monoclonal gammopathy of undetermined significance (MGUS)	Not a direct indication for melphalan but relevant in the diagnostic spectrum leading to multiple myeloma therapy decisions.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`96413`	Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug	Commonly billed for the first hour of an IV melphalan infusion in outpatient settings when infusion time fits the definition.
`96415`	Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary infusion)	Billed for additional infusion time beyond the first hour for prolonged melphalan administration.
`96365`	Intravenous infusion, therapeutic, prophylactic, or diagnostic; initial, up to 1 hour	May be used in some clinical workflows for certain infusions or hydration given with chemotherapy when chemotherapy-specific codes are not appropriate.
`36415`	Collection of venous blood by venipuncture	Often performed prior to melphalan administration to obtain labs (CBC, chemistries) required for dosing and safety.
`36561`	Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older, without subcutaneous port or pump	Used when central venous access is placed to facilitate melphalan infusion in selected patients.
`96360`	Intravenous infusion, hydration; initial, 31 minutes to 1 hour	Billed when IV hydration is provided as supportive care during melphalan administration.