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HCPCS J1813 · Level II · Part B drug

HCPCS J1813: Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50

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 J1813

Billing unit
50 UNITS
Lyumjev for insulin pump use
ASP payment limit
$3.903
October 2026; -18.7% vs July 2026
Practitioner MUE
none published
CMS publishes no MUE for this code
OPPS status
SI N
NCCI exposure
no PTP pairs
Coverage articles
0
none list this code

TL;DR

HCPCS J1813 is the Level II code for Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50, billed per 50 UNITS. The Medicare Part B ASP payment limit for October 2026 is $3.903 per billing unit, down 18.7% from July 2026. Under OPPS it carries status indicator N. J1813 is billed in units of 50 UNITS; 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 2 NDCs to it, sold as Lyumjev by Eli Lilly and Company, A-S Medication Solutions. No current Billing and Coding Article lists J1813, 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 J1813 at $3.903 per 50 UNITS for October 2026, derived from manufacturer average sales price plus 6%, compared with $4.802 in July 2026. Beneficiary coinsurance is 20%.

ASP payment limits for J1813
QuarterPayment limitPerCoinsurance
October 2026$3.90350 UNITS20%
July 2026$4.80250 UNITS—
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 2 NDCs from 2 labelers to J1813. Report the NDC in the claim's drug segment and bill the number of J1813 units that equals the quantity administered divided by 50 UNITS; the last column gives units per full package.

NDCs that crosswalk to J1813
NDCDrug nameLabelerPackage sizeBilling units / package
00002-7728-01LyumjevEli Lilly and Company10 × 120
50090-7433-00LyumjevA-S Medication Solutions10 × 120

Medically Unlikely Edits (MUE)

CMS does not publish an MUE for J1813 in the 2026 Q4 tables. Some MUE values are confidential and applied without publication, so unit limits can still deny; document the dose and the units calculation on every claim.

NCCI edits and add-on relationships

No active practitioner PTP pair lists J1813 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.

J1813 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 J1813 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, J1813 carries status indicator N. Status N means payment is packaged into the associated procedure and no separate OPPS payment is made.

Common denials for J1813 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 J1813 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 J1813

What does HCPCS code J1813 describe?

J1813 is defined by CMS as "Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50". Each billing unit represents 50 UNITS, so the units reported on the claim must equal the dose administered divided by that unit.

What is the Medicare reimbursement for J1813 in October 2026?

The ASP-based payment limit is $3.903 per 50 UNITS, with 20% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules. The July 2026 limit was $4.802.

Which NDCs map to J1813?

The October 2026 ASP crosswalk lists 2 NDCs from 2 labelers: Lyumjev (Eli Lilly and Company); Lyumjev (A-S Medication Solutions). For example NDC 00002-7728-01 is a 10 package equal to 20 billing units. The crosswalk's billing-units-per-package figure converts each package into J1813 units.

Does J1813 have NCCI bundling edits?

No active practitioner PTP pairs list J1813 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 2026-10-02. 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.