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HCPCS J0456 · Level II · Part B drug

HCPCS J0456: Injection, azithromycin, 500 mg

Reviewed by QuickIntell RCM Editorial Team · Last reviewed

Data effective
Data currency: ASP payment limits October 2026 (effective October 1, 2026); MUE and NCCI edits 2026 Q4 (effective October 1, 2026); OPPS Addendum B July 2026 (effective July 1, 2026). Next CMS release: January 1, 2027 (ASP, MUE, NCCI and OPPS quarterly updates).

Key facts for J0456

Billing unit
500 MG
Azithromycin
ASP payment limit
$2.571
October 2026; +36.1% vs July 2026
Practitioner MUE
4
MAI 3
OPPS status
SI N
NCCI exposure
no PTP pairs
Coverage articles
0
none list this code

TL;DR

HCPCS J0456 is the Level II code for Injection, azithromycin, 500 mg, billed per 500 MG. The Medicare Part B ASP payment limit for October 2026 is $2.571 per billing unit, up 36.1% from July 2026. The practitioner MUE allows up to 4 units per date of service (MAI 3). Under OPPS it carries status indicator N. J0456 is billed in units of 500 MG; the quantity administered, the NDC package and the units on the claim must reconcile, which is the check that prevents CARC 16 and 151 returns on this line. The ASP crosswalk maps 10 NDCs to it, sold as Zithromax, Azithromycin by Pfizer Inc, Sagent Pharmaceuticals, Eugia US LLC. No current Billing and Coding Article lists J0456, so coverage follows the FDA label, compendia and any applicable NCD.

Medicare Part B payment limit (ASP)

CMS sets the Part B payment limit for J0456 at $2.571 per 500 MG for October 2026, derived from manufacturer average sales price plus 6%, compared with $1.889 in July 2026. Beneficiary coinsurance is 20%.

ASP payment limits for J0456
QuarterPayment limitPerCoinsurance
October 2026$2.571500 MG20%
July 2026$1.889500 MG—
Source: CMS Medicare Part B Drug Payment Limit File. Commercial and Medicaid payers set their own rates.

NDC to HCPCS billing-unit conversion

The October 2026 ASP crosswalk maps 10 NDCs from 7 labelers to J0456. Report the NDC in the claim's drug segment and bill the number of J0456 units that equals the quantity administered divided by 500 MG; the last column gives units per full package.

NDCs that crosswalk to J0456
NDCDrug nameLabelerPackage sizeBilling units / package
00069-3150-83ZithromaxPfizer Inc1 × 1010
00409-0144-11AzithromycinPfizer Inc1 × 1010
25021-0180-66AzithromycinSagent Pharmaceuticals1 × 1010
55150-0174-10AzithromycinEugia US LLC1 × 1010
63323-0398-10AzithromycinFreseniUS Kabi USA, LLC1 × 1010
63323-0398-14AzithromycinFreseniUS Kabi USA, LLC1 × 1010
70095-0025-02AzithromycinSun Pharmaceutical Industries, Inc.1 × 1010
70436-0019-82AzithromycinSlate Run Pharmaceuticals1 × 1010
70860-0100-10AzithromycinAthenex Pharmaceutical Division, LLC1 × 1010
70860-0125-66AzithromycinAthenex Pharmaceutical Division, LLC1 × 1010

Medically Unlikely Edits (MUE)

CMS publishes 3 MUE values for J0456. For practitioners the limit is 4 units per date of service with adjudication indicator 3, a date-of-service clinical edit: units above the limit deny but can be paid on appeal with documentation that the quantity was medically reasonable.

MUE values for J0456 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services43 Date of Service Edit: ClinicalPrescribing Information
Facility outpatient hospital43 Date of Service Edit: ClinicalPrescribing Information
DME supplier03 Date of Service Edit: ClinicalCMS Policy

NCCI edits and add-on relationships

No active practitioner PTP pair lists J0456 as a column-1 or column-2 code in v323r0. Drug supply codes are rarely bundled; the administration codes billed with them are where PTP edits usually apply.

J0456 is neither an add-on code nor a designated primary code in the 2026 Q4 NCCI add-on edit file.

Medicare coverage articles

No current Billing and Coding Article lists J0456 in its HCPCS table. Coverage then follows the drug's FDA label, compendia and any National Coverage Determination; check the Medicare Coverage Database before administering off-label.

Hospital outpatient (OPPS) status

In the July 2026 OPPS Addendum B, J0456 carries status indicator N. Status N means payment is packaged into the associated procedure and no separate OPPS payment is made.

Common denials for J0456 and how to prevent them

CARC 16 · M119

NDC missing, invalid or not matched to the HCPCS code

CARC 151 · N362

units billed exceed the MUE for the date of service

CARC 50 · N115

diagnosis not covered by the applicable coverage article or LCD

How QuickIntell checks J0456 before the claim leaves

QuickCode validates the NDC-to-unit conversion against the current ASP crosswalk, checks units against every published MUE setting and flags PTP and add-on conflicts on the same claim. QuickRCM routes CARC 16, 151 and 50 denials on drug lines with the matching coverage article attached so the appeal starts with evidence.

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Frequently asked questions — HCPCS J0456

What does HCPCS code J0456 describe?

J0456 is defined by CMS as "Injection, azithromycin, 500 mg". Each billing unit represents 500 MG, so the units reported on the claim must equal the dose administered divided by that unit.

What is the Medicare reimbursement for J0456 in October 2026?

The ASP-based payment limit is $2.571 per 500 MG, with 20% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules. The July 2026 limit was $1.889.

How many units of J0456 can be billed per day?

The practitioner Medically Unlikely Edit is 4 units per date of service with adjudication indicator 3 (3 Date of Service Edit: Clinical). MAI 3 edits can be appealed with documentation that the units were medically reasonable. CMS cites "Prescribing Information" as the rationale.

Which NDCs map to J0456?

The October 2026 ASP crosswalk lists 10 NDCs from 7 labelers: Zithromax (Pfizer Inc); Azithromycin (Pfizer Inc); Azithromycin (Sagent Pharmaceuticals); Azithromycin (Eugia US LLC). For example NDC 00069-3150-83 is a 1 package equal to 10 billing units. The crosswalk's billing-units-per-package figure converts each package into J0456 units.

Does J0456 have NCCI bundling edits?

No active practitioner PTP pairs list J0456 as a column-1 or column-2 code in the v323r0 release. Unit limits (MUE) and medical-necessity coverage rules still apply.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-01. Verify against the primary file before billing or contracting decisions.

Disclaimer

This page is an operational reference compiled from CMS publications: the Medicare Part B drug payment limit and NDC crosswalk files, NCCI MUE and add-on edit tables, aggregate PTP statistics, OPPS Addendum B and the Medicare Coverage Database. Payment limits are Medicare national amounts; commercial and Medicaid payers differ. CPT codes are shown as numbers only; CPT descriptors are copyright AMA. Nothing here is legal, clinical or billing advice.