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HCPCS J7197 · Level II · Part B drug

HCPCS J7197: Antithrombin iii (human), per i.u.

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 J7197

Billing unit
1 IU
Antithrombin iii injection
ASP payment limit
$4.264
October 2026; +2.2% vs July 2026
Practitioner MUE
6300
MAI 1
OPPS status
SI K
APC 1263
NCCI exposure
no PTP pairs
Coverage articles
1
7 states

TL;DR

HCPCS J7197 is the Level II code for Antithrombin iii (human), per i.u., billed per 1 IU. The Medicare Part B ASP payment limit for October 2026 is $4.264 per billing unit, up 2.2% from July 2026. The practitioner MUE allows up to 6300 units per date of service (MAI 1). Under OPPS it carries status indicator K in APC 1263. J7197 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. The ASP crosswalk maps 2 NDCs to it, sold as Thrombate III by Grifols USA, LLC. 1 Medicare coverage article lists the code across 7 states, including .

Medicare Part B payment limit (ASP)

CMS sets the Part B payment limit for J7197 at $4.264 per 1 IU for October 2026, derived from manufacturer average sales price plus 6%, compared with $4.174 in July 2026. Beneficiary coinsurance is 20%.

ASP payment limits for J7197
QuarterPayment limitPerCoinsurance
October 2026$4.2641 IU20%
July 2026$4.1741 IU—
CMS note: Inflation-adjusted coinsurance

NDC to HCPCS billing-unit conversion

The October 2026 ASP crosswalk maps 2 NDCs from 1 labeler to J7197. Report the NDC in the claim's drug segment and bill the number of J7197 units that equals the quantity administered divided by 1 IU; the last column gives units per full package.

NDCs that crosswalk to J7197
NDCDrug nameLabelerPackage sizeBilling units / package
13533-0602-50Thrombate IIIGrifols USA, LLC1 × 11
13533-0606-12Thrombate IIIGrifols USA, LLC1 × 11

Medically Unlikely Edits (MUE)

CMS publishes 2 MUE values for J7197. For practitioners the limit is 6300 units per date of service with adjudication indicator 1, a claim-line edit: units above the limit deny on that line, and documented separate services can be reported on another line with an appropriate modifier.

MUE values for J7197 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services63001 Line EditPrescribing Information
Facility outpatient hospital63001 Line EditPrescribing Information

NCCI edits and add-on relationships

No active practitioner PTP pair lists J7197 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.

J7197 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 J7197 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 J7197
ArticleTitleContractor(s)StatesRelated LCD
Billing 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 July 2026 OPPS Addendum B, J7197 carries status indicator K and is assigned to APC 1263, with a published national unadjusted payment of $4.17. Status K means the drug is paid separately under OPPS at the ASP-based rate rather than packaged into the procedure.

Common denials for J7197 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 J7197 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 J7197

What does HCPCS code J7197 describe?

J7197 is defined by CMS as "Antithrombin iii (human), per i.u.". Each billing unit represents 1 IU, so the units reported on the claim must equal the dose administered divided by that unit.

What is the Medicare reimbursement for J7197 in October 2026?

The ASP-based payment limit is $4.264 per 1 IU, with 20% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules. The July 2026 limit was $4.174.

How many units of J7197 can be billed per day?

The practitioner Medically Unlikely Edit is 6300 units per date of service with adjudication indicator 1 (1 Line Edit). MAI 1 edits apply per claim line; units may be split across lines with an appropriate modifier when justified. CMS cites "Prescribing Information" as the rationale.

Which NDCs map to J7197?

The October 2026 ASP crosswalk lists 2 NDCs from 1 labeler: Thrombate III (Grifols USA, LLC). For example NDC 13533-0602-50 is a 1 package equal to 1 billing unit. The crosswalk's billing-units-per-package figure converts each package into J7197 units.

Does J7197 have NCCI bundling edits?

No active practitioner PTP pairs list J7197 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 J7197?

1 current Billing and Coding Article in the Medicare Coverage Database list J7197, covering 7 states: (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 2026-10-01. 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.