J1097 HCPCS code: Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml
J1097 is the HCPCS Level II code for phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml. In 2024 Medicare paid an average of $75.94 per service for J1097 across 699,338 services. Its Medicare coverage code is C (Carrier judgment): Coverage is decided by the Medicare contractor (MAC) case by case. The NCCI unit limit is 4 per day on outpatient hospital claims. Medicare volume fell 18% from 2022 to 2024 (848,018 to 699,338 services). In 2024, about 509 clinicians billed Medicare for J1097 for 107,019 beneficiaries; Florida, California, Virginia accounted for 20% of services.
Code details
| Field | Value |
|---|---|
| Section | J codes — Drugs administered other than oral method |
| Coverage code | C — Carrier judgment |
| Pricing indicator | 51 — Drug or biological (priced per ASP/average sales price rules) |
| BETOS category | O1E — Other drugs |
| Added | 2019-10-01 |
| Last action effective | 2019-10-01 |
Who bills J1097 (2024)
| Measure | Value |
|---|---|
| Clinicians billing (by place of service) | 509 |
| Medicare beneficiaries | 107,019 |
| States with claims | 46 |
| Share of services in top 3 states (Florida, California, Virginia) | 20% |
Counts only. Supplier and clinician names, contact lists and state-by-state detail are in Caduvo.
Medicare utilization for J1097, 2022–2024
| Year | Services | Beneficiaries | Avg. allowed | Avg. paid |
|---|---|---|---|---|
| 2022 | 848,018 | 130,254 | $96.71 | $77.16 |
| 2023 | 855,131 | 131,012 | $95.35 | $76.05 |
| 2024 | 699,338 | 107,019 | $95.34 | $75.94 |
States with the most J1097 services (2024)
| State | Services | Avg. paid |
|---|---|---|
| Florida | 52,907 | $76.06 |
| California | 49,143 | $76.04 |
| Virginia | 37,494 | $76.10 |
| New York | 36,096 | $76.07 |
| New Jersey | 34,666 | $76.08 |
NCCI unit limits (MUE)
| Claim type | Max units per day | Rationale |
|---|---|---|
| outpatient hospital claims | 4 | Prescribing Information |
| practitioner claims | 4 | Prescribing Information |
What changed for J1097
- 2019-10-01: J1097 added to HCPCS Level II
- Next scheduled CMS quarterly update (HCPCS and DMEPOS fee schedule): 2027-01-01
Frequently asked questions
What is HCPCS code J1097?
J1097 is the HCPCS Level II code for phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml. Short descriptor: "Phenylep ketorolac opth soln".
How much does Medicare pay for J1097?
In 2024, the average Medicare payment was $75.94 per service (average allowed $95.34).
Does Medicare cover J1097?
Coverage code C — Carrier judgment. Coverage is decided by the Medicare contractor (MAC) case by case.
How many units of J1097 can be billed per day?
4 on outpatient hospital claims; 4 on practitioner claims (NCCI medically unlikely edits).
Related J10 codes
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Next steps
- Run a reimbursement report for a device billed under J1097
- Watch J1097 for fee, coverage and descriptor changes
- Build a full Medicare revenue model for J1097
Sources: CMS HCPCS Level II release October 2026; CMS DMEPOS fee schedule; CMS NCCI MUE tables; CMS Medicare utilization (physician and DME supplier files); CMS Medicare Coverage Database articles. Fees are Medicare allowables, not commercial rates. Not billing or legal advice.