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HCPCS J0897 · Level II · Part B drug

HCPCS J0897: Injection, denosumab, 1 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 J0897

Billing unit
1 MG
Denosumab injection
ASP payment limit
$29.856
October 2026; -0.8% vs July 2026
Practitioner MUE
120
MAI 3
OPPS status
SI K
APC 9272
NCCI exposure
no PTP pairs
Coverage articles
1
5 states

TL;DR

HCPCS J0897 is the Level II code for Injection, denosumab, 1 mg, billed per 1 MG. The Medicare Part B ASP payment limit for October 2026 is $29.856 per billing unit, down 0.8% from July 2026. The practitioner MUE allows up to 120 units per date of service (MAI 3). Under OPPS it carries status indicator K in APC 9272. With a 1 mg billing unit, a single administration can be hundreds of units; the unit count on the claim must equal the milligrams given, and rounding rules for partial units follow the contractor's guidance. The ASP crosswalk maps 4 NDCs to it, sold as Prolia, Xgeva by Amgen Inc. 1 Medicare coverage article lists the code across 5 states, including .

Medicare Part B payment limit (ASP)

CMS sets the Part B payment limit for J0897 at $29.856 per 1 MG for October 2026, derived from manufacturer average sales price plus 6%, compared with $30.101 in July 2026. Beneficiary coinsurance is 18%.

ASP payment limits for J0897
QuarterPayment limitPerCoinsurance
October 2026$29.8561 MG18%
July 2026$30.1011 MG—
CMS note: Inflation-adjusted coinsurance

NDC to HCPCS billing-unit conversion

The October 2026 ASP crosswalk maps 4 NDCs from 1 labeler to J0897. Report the NDC in the claim's drug segment and bill the number of J0897 units that equals the quantity administered divided by 1 MG; the last column gives units per full package.

NDCs that crosswalk to J0897
NDCDrug nameLabelerPackage sizeBilling units / package
55513-0710-01ProliaAmgen Inc1 × 160
55513-0710-21ProliaAmgen Inc1 × 160
55513-0730-01XgevaAmgen Inc1 × 1120
55513-0730-21XgevaAmgen Inc1.7 × 1120

Medically Unlikely Edits (MUE)

CMS publishes 3 MUE values for J0897. For practitioners the limit is 120 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 J0897 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services1203 Date of Service Edit: ClinicalPrescribing Information
Facility outpatient hospital1203 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 J0897 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.

J0897 is neither an add-on code nor a designated primary code in the 2026 Q4 NCCI add-on edit file.

Medicare coverage articles

1 current Medicare Administrative Contractor article lists J0897 in their HCPCS tables, covering 5 states. Each article carries the covered and non-covered ICD-10 codes that medical-necessity denials (CARC 50) are adjudicated against.

Billing and Coding Articles listing J0897
ArticleTitleContractor(s)StatesRelated LCD
Billing and Coding: Denosumab (Prolia®, Xgeva®, Jubbonti®) and biosimilarsWellpoint FederalCT IL MN NY WIL33394

Hospital outpatient (OPPS) status

In the July 2026 OPPS Addendum B, J0897 carries status indicator K and is assigned to APC 9272, with a published national unadjusted payment of $30.10. Status K means the drug is paid separately under OPPS at the ASP-based rate rather than packaged into the procedure.

Common denials for J0897 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 J0897 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 J0897

What does HCPCS code J0897 describe?

J0897 is defined by CMS as "Injection, denosumab, 1 mg". Each billing unit represents 1 MG, so the units reported on the claim must equal the dose administered divided by that unit.

What is the Medicare reimbursement for J0897 in October 2026?

The ASP-based payment limit is $29.856 per 1 MG, with 18% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules. The July 2026 limit was $30.101.

How many units of J0897 can be billed per day?

The practitioner Medically Unlikely Edit is 120 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 J0897?

The October 2026 ASP crosswalk lists 4 NDCs from 1 labeler: Prolia (Amgen Inc); Xgeva (Amgen Inc). For example NDC 55513-0710-01 is a 1 package equal to 60 billing units. The crosswalk's billing-units-per-package figure converts each package into J0897 units.

Does J0897 have NCCI bundling edits?

No active practitioner PTP pairs list J0897 as a column-1 or column-2 code in the v323r0 release. Unit limits (MUE) and medical-necessity coverage rules still apply.

Which Medicare coverage articles mention J0897?

1 current Billing and Coding Article in the Medicare Coverage Database list J0897, covering 5 states: (Billing and Coding: Denosumab (Prolia®, Xgeva®, Jubbonti®) and biosimilars).

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.