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HCPCS J7168 · Level II · Part B drug

J7168: prothrombin complex concentrate (Kcentra), HCPCS Level II J code

Compiled from CMS files by the QuickIntell RCM Editorial Team · Data effective · Method: reference methodology · Report a data correction

Data currency: OPPS Addendum B: October 2026 (effective October 1, 2026); OPPS NDC-HCPCS crosswalk: October 2026 (effective October 1, 2026); NCCI MUE tables: 2026 Q4 (effective October 1, 2026); NCCI PTP edits: v323r0 (2026 Q4) (effective October 1, 2026); ASC Addendum BB (covered ancillary services): October 2026 (effective October 1, 2026). Next CMS release: January 1, 2027 (quarterly update).

Key facts for J7168

Billing unit
1 IU
Prothrombin complex kcentra
OPPS payment rate
$1.901
no ASP limit; SI K, October 2026
Practitioner MUE
5000
MAI 3
OPPS status
SI K
APC 9132
NCCI exposure
no PTP pairs
Coverage articles
0
none list this code

TL;DR

HCPCS J7168 is the Level II code for Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity, billed per 1 IU. CMS publishes no ASP payment limit for it; hospital outpatient departments are paid separately under OPPS (status indicator K, $1.901 per billing unit in October 2026). The practitioner MUE allows up to 5000 units per date of service (MAI 3). J7168 is billed in units of 1 IU; 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. Other HCPCS codes whose descriptor names prothrombin complex concentrate: J7165 (Balfaxar from Octapharma USA Inc.; billed per FACTOR IX IU). The OPPS crosswalk maps 2 NDCs to it, sold as Kcentra by CSL Behring L.L.C. No current Billing and Coding Article lists J7168, so coverage follows the FDA label, compendia and any applicable NCD.

Medicare payment: OPPS rate (no ASP limit)

J7168 does not appear in the October 2026 Part B ASP payment limit file. CMS pays it separately to hospital outpatient departments under OPPS with status indicator K in APC 9132, at a national unadjusted rate of $1.901 per 1 IU. Status K is a separately paid, non-pass-through drug or biological, including therapeutic radiopharmaceuticals. In a physician office the Medicare contractor prices the drug, often from invoice; commercial and Medicaid payers set their own rates.

NDC to HCPCS billing-unit conversion

The October 2026 OPPS crosswalk maps 2 NDCs from 1 labeler to J7168. Report the NDC in the claim's drug segment and bill the number of J7168 units that equals the quantity administered divided by 1 IU; the last column gives units per full package.

NDCs that crosswalk to J7168
NDCDrug nameLabelerPackage sizeBilling units / package
63833-0386-02KcentraCSL Behring L.L.C.1 × 11
63833-0387-02KcentraCSL Behring L.L.C.1 × 11

Medically Unlikely Edits (MUE)

CMS publishes 2 MUE values for J7168. For practitioners the limit is 5000 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 J7168 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services50003 Date of Service Edit: ClinicalPrescribing Information
Facility outpatient hospital50003 Date of Service Edit: ClinicalPrescribing Information

MUE for J7168 in every setting opens the lookup with this code filled in, next to any other code on the same claim.

NCCI edits and add-on relationships

No active practitioner PTP pair lists J7168 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.

The counts above are exposure, not answers for a specific claim. Check J7168 against another code to see whether a given pair bundles, which code is paid and whether a modifier can separate them.

J7168 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 J7168 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 October 2026 OPPS Addendum B, J7168 carries status indicator K and is assigned to APC 9132, with a published national unadjusted payment of $1.901. Status K means the drug is paid separately under OPPS rather than packaged into the procedure.

Ambulatory surgical center (ASC) payment

In the October 2026 ASC Addendum BB (covered ancillary services), J7168 carries payment indicator K2, which CMS defines as "Drugs, biologicals, and radiopharmaceuticals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate". The national ASC payment is $1.90 per 1 IU, paid only when the drug is furnished integral to a covered surgical procedure.

Common denials for J7168 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 J7168 before the claim leaves

QuickCode validates the NDC-to-unit conversion against the current OPPS NDC-HCPCS 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 J7168

What does HCPCS code J7168 describe?

J7168 is defined by CMS as "Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity". Each billing unit represents 1 IU, so the units reported on the claim must equal the dose administered divided by that unit.

Is J7168 a CPT code?

No. J7168 is a HCPCS Level II code, the letter-plus-four-digit set CMS maintains for drugs such as prothrombin complex concentrate (Kcentra); CPT codes are five-character codes maintained by the AMA. On a Part B claim J7168 reports the drug itself in 1 IU units, and the administration is billed on its own line.

What does Medicare pay for J7168 in a hospital outpatient department?

J7168 has no Part B ASP limit; the October 2026 OPPS Addendum B pays it separately under status K, APC 9132, at $1.901 per 1 IU, and ASC Addendum BB gives it payment indicator K2 at $1.90.

How many units of J7168 can be billed per day?

The practitioner Medically Unlikely Edit is 5000 units per date of service with adjudication indicator 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 J7168?

The October 2026 OPPS crosswalk lists 2 NDCs from 1 labeler: Kcentra (CSL Behring L.L.C.). For example NDC 63833-0386-02 (package size 1) equals 1 billing unit of J7168.

Does J7168 have NCCI bundling edits?

No active practitioner PTP pairs list J7168 as a column-1 or column-2 code in the v323r0 release.

J7168 vs J7165: what is the difference?

Both are HCPCS Level II codes whose descriptor names prothrombin complex concentrate. What sets J7165 apart: Balfaxar from Octapharma USA Inc.; billed per FACTOR IX IU. J7168 is billed per 1 iu, OPPS rate $1.901, MUE 5000; J7165 is billed per per factor ix iu, OPPS rate $1.714, MUE 5000. Report the code whose descriptor matches the product and setting in the record.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.

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, ASC Addendum BB and the Medicare Coverage Database. Payment limits and rates 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.

Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.