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HCPCS Q2043 · Level II · Part B drug

HCPCS Q2043: Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with

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 Q2043

Billing unit
Per infusion (minimum 50 million cells)
Sipuleucel-t auto cd54+
ASP payment limit
$55,663.131
October 2026; -0.5% vs July 2026
Practitioner MUE
1
MAI 2
OPPS status
SI K
APC 9273
NCCI exposure
1 col-2 pairs
100% allow a modifier
Coverage articles
1
6 states

TL;DR

HCPCS Q2043 is the Level II code for Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with, billed per Per infusion (minimum 50 million cells). The Medicare Part B ASP payment limit for October 2026 is $55,663.131 per billing unit, down 0.5% from July 2026. The practitioner MUE allows up to 1 units per date of service (MAI 2). Under OPPS it carries status indicator K in APC 9273. Q2043 is billed in units of Per infusion (minimum 50 million cells); 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 1 NDC to it, sold as Provenge by Dendreon Pharmaceuticals LLC. It is the bundled column-2 code in 1 NCCI pair, most often with 36522. 1 Medicare coverage article lists the code across 6 states, including .

Medicare Part B payment limit (ASP)

CMS sets the Part B payment limit for Q2043 at $55,663.131 per Per infusion (minimum 50 million cells) for October 2026, derived from manufacturer average sales price plus 6%, compared with $55,932.427 in July 2026. Beneficiary coinsurance is 20%.

ASP payment limits for Q2043
QuarterPayment limitPerCoinsurance
October 2026$55,663.131Per infusion (minimum 50 million cells)20%
July 2026$55,932.427Per infusion (minimum 50 million cells)—
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 1 NDC from 1 labeler to Q2043. Report the NDC in the claim's drug segment and bill the number of Q2043 units that equals the quantity administered divided by Per infusion (minimum 50 million cells); the last column gives units per full package.

NDCs that crosswalk to Q2043
NDCDrug nameLabelerPackage sizeBilling units / package
30237-8900-06ProvengeDendreon Pharmaceuticals LLC250 × 11

Medically Unlikely Edits (MUE)

CMS publishes 2 MUE values for Q2043. For practitioners the limit is 1 unit per date of service with adjudication indicator 2, a date-of-service policy edit: the limit reflects CMS policy and units above it deny even if split across lines; appeals rarely succeed.

MUE values for Q2043 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services12 Date of Service Edit: PolicyCode Descriptor / CPT Instruction
Facility outpatient hospital12 Date of Service Edit: PolicyCode Descriptor / CPT Instruction

NCCI edits and add-on relationships

In the practitioner PTP file v323r0 (effective October 1, 2026), Q2043 is the column-2 code in 1 active pair, 100% of which allow a modifier (indicator 1), and the column-1 code in 171. 113 historical pairs have been deleted over time. CMS's most frequent rationale: Mutually exclusive procedures.

When billed with these column-1 codes, Q2043 is the bundled component unless the pair allows a modifier and the documentation supports a distinct service.

Column-1 codes most often paired with Q2043
Column-1 codePairs
36522 (CPT; descriptor licensed by AMA)1

These codes are considered components of Q2043 when reported together on the same date of service.

Column-2 codes most often bundled into Q2043
Column-2 codePairs
0213T (CPT; descriptor licensed by AMA)1
0216T (CPT; descriptor licensed by AMA)1
0596T (CPT; descriptor licensed by AMA)1
0597T (CPT; descriptor licensed by AMA)1
0692T (CPT; descriptor licensed by AMA)1
0903T (CPT; descriptor licensed by AMA)1
0904T (CPT; descriptor licensed by AMA)1
0905T (CPT; descriptor licensed by AMA)1
36000 (CPT; descriptor licensed by AMA)1
36400 (CPT; descriptor licensed by AMA)1

Q2043 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 Q2043 in their HCPCS tables, covering 6 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 Q2043
ArticleTitleContractor(s)StatesRelated LCD
Sipuleucel-T (Provenge®) - Coverage Criteria for Prostate Cancer – ClarificationNoridian Healthcare Solutions, LLCAZ MT ND SD UT WY—

Hospital outpatient (OPPS) status

In the July 2026 OPPS Addendum B, Q2043 carries status indicator K and is assigned to APC 9273, with a published national unadjusted payment of $55,932.43. Status K means the drug is paid separately under OPPS at the ASP-based rate rather than packaged into the procedure.

Common denials for Q2043 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 Q2043 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 Q2043

What does HCPCS code Q2043 describe?

Q2043 is defined by CMS as "Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with". Each billing unit represents Per infusion (minimum 50 million cells), so the units reported on the claim must equal the dose administered divided by that unit.

What is the Medicare reimbursement for Q2043 in October 2026?

The ASP-based payment limit is $55,663.131 per Per infusion (minimum 50 million cells), with 20% beneficiary coinsurance. Medicare Administrative Contractors apply this limit; commercial payers use their own fee schedules. The July 2026 limit was $55,932.427.

How many units of Q2043 can be billed per day?

The practitioner Medically Unlikely Edit is 1 units per date of service with adjudication indicator 2 (2 Date of Service Edit: Policy). MAI 2 edits are policy limits and are rarely overturned on appeal. CMS cites "Code Descriptor / CPT Instruction" as the rationale.

Which NDCs map to Q2043?

The October 2026 ASP crosswalk lists 1 NDC from 1 labeler: Provenge (Dendreon Pharmaceuticals LLC). For example NDC 30237-8900-06 is a 250 package equal to 1 billing unit. The crosswalk's billing-units-per-package figure converts each package into Q2043 units.

Does Q2043 have NCCI bundling edits?

In the v323r0 practitioner PTP file, Q2043 appears as the column-2 (bundled) code in 1 active pairs and as the column-1 code in 171. 100% of the column-2 pairs allow a modifier (indicator 1). The most frequent column-1 partners are 36522, and CMS's leading rationale is "Mutually exclusive procedures".

Which Medicare coverage articles mention Q2043?

1 current Billing and Coding Article in the Medicare Coverage Database list Q2043, covering 6 states: (Sipuleucel-T (Provenge®) - Coverage Criteria for Prostate Cancer – Clarification).

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.