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HCPCS J2794 · Level II · Part B drug

HCPCS J2794: Injection, risperidone (risperdal consta), 0.5 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 J2794

Billing unit
0.5 MG
Inj risperdal consta, 0.5 mg
ASP payment limit
$10.662
October 2026; -4.0% vs July 2026
Practitioner MUE
100
MAI 3
OPPS status
SI K
APC 9125
NCCI exposure
no PTP pairs
Coverage articles
0
none list this code

TL;DR

HCPCS J2794 is the Level II code for Injection, risperidone (risperdal consta), 0.5 mg, billed per 0.5 MG. The Medicare Part B ASP payment limit for October 2026 is $10.662 per billing unit, down 4.0% from July 2026. The practitioner MUE allows up to 100 units per date of service (MAI 3). Under OPPS it carries status indicator K in APC 9125. J2794 is billed in units of 0.5 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 14 NDCs to it, sold as Risperidone ER, Risperdal Consta by Teva Pharmaceuticals USA, Inc., Janssen Pharmaceuticals, Inc., Amneal Pharmaceuticals, LLC. No current Billing and Coding Article lists J2794, 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 J2794 at $10.662 per 0.5 MG for October 2026, derived from manufacturer average sales price plus 6%, compared with $11.105 in July 2026. Beneficiary coinsurance is 20%.

ASP payment limits for J2794
QuarterPayment limitPerCoinsurance
October 2026$10.6620.5 MG20%
July 2026$11.1050.5 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 14 NDCs from 4 labelers to J2794. Report the NDC in the claim's drug segment and bill the number of J2794 units that equals the quantity administered divided by 0.5 MG; the last column gives units per full package.

NDCs that crosswalk to J2794
NDCDrug nameLabelerPackage sizeBilling units / package
00480-1232-08Risperidone ERTeva Pharmaceuticals USA, Inc.1 × 150
00480-1342-08Risperidone ERTeva Pharmaceuticals USA, Inc.1 × 175
00480-1453-08Risperidone ERTeva Pharmaceuticals USA, Inc.1 × 1100
00480-1554-08Risperidone ERTeva Pharmaceuticals USA, Inc.1 × 125
50458-0306-11Risperdal ConstaJanssen Pharmaceuticals, Inc.1 × 150
50458-0307-11Risperdal ConstaJanssen Pharmaceuticals, Inc.1 × 175
50458-0308-11Risperdal ConstaJanssen Pharmaceuticals, Inc.1 × 1100
50458-0309-11Risperdal ConstaJanssen Pharmaceuticals, Inc.1 × 125
70121-2626-05Risperidone ERAmneal Pharmaceuticals, LLC1 × 150
70121-2627-05Risperidone ERAmneal Pharmaceuticals, LLC1 × 175
70121-2628-05Risperidone ERAmneal Pharmaceuticals, LLC1 × 1100
70748-0270-13Risperidone ERLupin Pharmaceuticals, Inc.1 × 150
70748-0271-13Risperidone ERLupin Pharmaceuticals, Inc.1 × 175
70748-0272-13Risperidone ERLupin Pharmaceuticals, Inc.1 × 1100

Medically Unlikely Edits (MUE)

CMS publishes 3 MUE values for J2794. For practitioners the limit is 100 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 J2794 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services1003 Date of Service Edit: ClinicalPrescribing Information
Facility outpatient hospital1003 Date of Service Edit: ClinicalPrescribing Information
DME supplier1003 Date of Service Edit: ClinicalPrescribing Information

NCCI edits and add-on relationships

No active practitioner PTP pair lists J2794 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.

J2794 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 J2794 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, J2794 carries status indicator K and is assigned to APC 9125, with a published national unadjusted payment of $11.11. Status K means the drug is paid separately under OPPS at the ASP-based rate rather than packaged into the procedure.

Common denials for J2794 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 J2794 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.

Explore QuickCodeExplore QuickRCMBook a demo

Frequently asked questions — HCPCS J2794

What does HCPCS code J2794 describe?

J2794 is defined by CMS as "Injection, risperidone (risperdal consta), 0.5 mg". Each billing unit represents 0.5 MG, so the units reported on the claim must equal the dose administered divided by that unit.

What is the Medicare reimbursement for J2794 in October 2026?

The ASP-based payment limit is $10.662 per 0.5 MG, with 20% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules. The July 2026 limit was $11.105.

How many units of J2794 can be billed per day?

The practitioner Medically Unlikely Edit is 100 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 J2794?

The October 2026 ASP crosswalk lists 14 NDCs from 4 labelers: Risperidone ER (Teva Pharmaceuticals USA, Inc.); Risperdal Consta (Janssen Pharmaceuticals, Inc.); Risperidone ER (Amneal Pharmaceuticals, LLC); Risperidone ER (Lupin Pharmaceuticals, Inc.). For example NDC 00480-1232-08 is a 1 package equal to 50 billing units. The crosswalk's billing-units-per-package figure converts each package into J2794 units.

Does J2794 have NCCI bundling edits?

No active practitioner PTP pairs list J2794 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.