Skip to main content
HCPCS Q0224 · Level II · Part B drug

HCPCS Q0224: Injection, pemivibart, for the pre-exposure prophylaxis only, for certain

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 Q0224

Billing unit
4500 MG
Inj, pemivibart, 4500 mg
ASP payment limit
$7,615.20
October 2026; +5.2% vs July 2026
Practitioner MUE
1
MAI 3
OPPS status
SI L
NCCI exposure
no PTP pairs
Coverage articles
0
none list this code

TL;DR

HCPCS Q0224 is the Level II code for Injection, pemivibart, for the pre-exposure prophylaxis only, for certain, billed per 4500 MG. The Medicare Part B ASP payment limit for October 2026 is $7,615.20 per billing unit, up 5.2% from July 2026. The practitioner MUE allows up to 1 units per date of service (MAI 3). Under OPPS it carries status indicator L. Q0224 is billed in units of 4500 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. No current Billing and Coding Article lists Q0224, 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 Q0224 at $7,615.20 per 4500 MG for October 2026, derived from manufacturer average sales price plus 6%, compared with $7,239.00 in July 2026. Beneficiary coinsurance is 0%.

ASP payment limits for Q0224
QuarterPayment limitPerCoinsurance
October 2026$7,615.204500 MG0%
July 2026$7,239.004500 MG—
CMS note: See COVID-19 vaccine pricing webpage for payment effective dates

NDC to HCPCS billing-unit conversion

The October 2026 ASP crosswalk lists no NDC for Q0224. Report the NDC from the product label and confirm the units conversion from the HCPCS descriptor (Injection, pemivibart, for the pre-exposure prophylaxis only, for certain).

Medically Unlikely Edits (MUE)

CMS publishes 2 MUE values for Q0224. For practitioners the limit is 1 unit 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 Q0224 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services13 Date of Service Edit: ClinicalPrescribing Information
Facility outpatient hospital13 Date of Service Edit: ClinicalPrescribing Information

NCCI edits and add-on relationships

No active practitioner PTP pair lists Q0224 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.

Q0224 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 Q0224 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, Q0224 carries status indicator L. Consult the OPPS status indicator table for payment treatment.

Common denials for Q0224 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 Q0224 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 Q0224

What does HCPCS code Q0224 describe?

Q0224 is defined by CMS as "Injection, pemivibart, for the pre-exposure prophylaxis only, for certain". Each billing unit represents 4500 MG, so the units reported on the claim must equal the dose administered divided by that unit.

What is the Medicare reimbursement for Q0224 in October 2026?

The ASP-based payment limit is $7,615.20 per 4500 MG, with 0% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules. The July 2026 limit was $7,239.00.

How many units of Q0224 can be billed per day?

The practitioner Medically Unlikely Edit is 1 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.

Does Q0224 have NCCI bundling edits?

No active practitioner PTP pairs list Q0224 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.