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HCPCS J7191 · Level II · Part B drug

J7191: factor VIII, 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 J7191

Billing unit
per descriptor
Factor viii (porcine)
OPPS payment rate
$5.46
no ASP limit; SI K, October 2026
Practitioner MUE
0
MAI 3
OPPS status
SI K
APC 1464
NCCI exposure
no PTP pairs
Coverage articles
1
7 states

TL;DR

HCPCS J7191 is the Level II code for Factor viii (antihemophilic factor (porcine)), per i.u., billed per unit. CMS publishes no ASP payment limit for it; hospital outpatient departments are paid separately under OPPS (status indicator K, $5.46 per billing unit in October 2026). The practitioner MUE allows up to 0 units per date of service (MAI 3). J7191 is billed in units of the descriptor quantity; 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 factor VIII: J7190 (billed per 1 IU); J7192 (not otherwise specified (for products without their own code); billed per 1 IU); J7188 (Obizur from Takeda Pharmaceuticals America, Inc.; billed per 1 IU); J7185 (Xyntha from Pfizer Inc; billed per 1 IU); J7182 (Novoeight from Novo Nordisk, Inc; billed per 1 IU); J7204 (Esperoct from Novo Nordisk, Inc; billed per 1 IU). 1 Medicare coverage article lists the code across 7 states, including A56065.

Medicare payment: OPPS rate (no ASP limit)

J7191 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 1464, at a national unadjusted rate of $5.46 per billing unit. 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 lists no NDC for J7191. Report the NDC from the product label and confirm the units conversion from the HCPCS descriptor (Factor viii (antihemophilic factor (porcine)), per i.u.).

Medically Unlikely Edits (MUE)

CMS publishes 2 MUE values for J7191. For practitioners the limit is 0 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 J7191 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services03 Date of Service Edit: ClinicalDrug discontinued
Facility outpatient hospital03 Date of Service Edit: ClinicalDrug discontinued

MUE for J7191 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 J7191 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 J7191 against another code to see whether a given pair bundles, which code is paid and whether a modifier can separate them.

J7191 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 J7191 in their HCPCS tables, covering 7 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 J7191
ArticleTitleContractor(s)StatesRelated LCD
A56065Billing and Coding: Guidance for Anti-Inhibitor Coagulant Complex (AICC) National Coverage Determination (NCD) 110.3Palmetto GBAAL GA NC SC TN VA WV—

Hospital outpatient (OPPS) status

In the October 2026 OPPS Addendum B, J7191 carries status indicator K and is assigned to APC 1464, with a published national unadjusted payment of $5.46. 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), J7191 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 $5.46 per billing unit, paid only when the drug is furnished integral to a covered surgical procedure.

Common denials for J7191 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 J7191 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 J7191

What does HCPCS code J7191 describe?

J7191 is defined by CMS as "Factor viii (antihemophilic factor (porcine)), per i.u.". Each billing unit represents the quantity in the descriptor, so the units reported on the claim must equal the dose administered divided by that unit.

Is J7191 a CPT code?

No. J7191 is a HCPCS Level II code, the letter-plus-four-digit set CMS maintains for drugs such as factor VIII; CPT codes are five-character codes maintained by the AMA. On a Part B claim J7191 reports the drug itself, and the administration is billed on its own line.

What does Medicare pay for J7191 in a hospital outpatient department?

J7191 has no Part B ASP limit; the October 2026 OPPS Addendum B pays it separately under status K, APC 1464, at $5.46 per billing unit, and ASC Addendum BB gives it payment indicator K2 at $5.46.

How many units of J7191 can be billed per day?

The practitioner Medically Unlikely Edit is 0 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 "Drug discontinued" as the rationale.

Does J7191 have NCCI bundling edits?

No active practitioner PTP pairs list J7191 as a column-1 or column-2 code in the v323r0 release.

J7191 vs J7190: what is the difference?

Both are HCPCS Level II codes whose descriptor names factor VIII. What sets J7190 apart: billed per 1 IU. J7191 is OPPS rate $5.46, MUE 0; J7190 is billed per 1 iu, limit $1.248, MUE 22000. Report the code whose descriptor matches the product and setting in the record.

J7191 vs J7192: what is the difference?

Both are HCPCS Level II codes whose descriptor names factor VIII. What sets J7192 apart: not otherwise specified (for products without their own code); billed per 1 IU. J7191 is OPPS rate $5.46, MUE 0; J7192 is billed per 1 iu, limit $1.616, MUE 22000. Report the code whose descriptor matches the product and setting in the record.

Which Medicare coverage articles mention J7191?

1 current Billing and Coding Article in the Medicare Coverage Database lists J7191, covering 7 states: A56065 (Billing and Coding: Guidance for Anti-Inhibitor Coagulant Complex (AICC) National Coverage Determination (NCD) 110.3).

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.