J1438 HCPCS code: Injection, etanercept, 25 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)
J1438 is the HCPCS Level II code for injection, etanercept, 25 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered). Its Medicare coverage code is D (Special coverage instructions apply): Medicare covers it when its national or local coverage criteria are met. The NCCI unit limit is 2 per day on outpatient hospital claims.
Code details
| Field | Value |
|---|---|
| Section | J codes — Drugs administered other than oral method |
| Coverage code | D — Special coverage instructions apply |
| Pricing indicator | 51 — Drug or biological (priced per ASP/average sales price rules) |
| BETOS category | O1E — Other drugs |
| Added | 2000-01-01 |
| Last action effective | 2000-01-01 |
NCCI unit limits (MUE)
| Claim type | Max units per day | Rationale |
|---|---|---|
| outpatient hospital claims | 2 | Prescribing Information |
| practitioner claims | 2 | Prescribing Information |
What changed for J1438
- 2000-01-01: J1438 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 J1438?
J1438 is the HCPCS Level II code for injection, etanercept, 25 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered). Short descriptor: "Etanercept injection".
Does Medicare cover J1438?
Coverage code D — Special coverage instructions apply. Medicare covers it when its national or local coverage criteria are met.
How many units of J1438 can be billed per day?
2 on outpatient hospital claims; 2 on practitioner claims (NCCI medically unlikely edits).
Related J14 codes
- J1410 — Injection, estrogen conjugated, per 25 mg
- J1411 — Injection, etranacogene dezaparvovec-drlb, per therapeutic dose
- J1412 — Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes
- J1413 — Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose
- J1414 — Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose
- J1426 — Injection, casimersen, 10 mg
- J1427 — Injection, viltolarsen, 10 mg
- J1428 — Injection, eteplirsen, 10 mg
- J1429 — Injection, golodirsen, 10 mg
- J1430 — Injection, ethanolamine oleate, 100 mg
- J1434 — Injection, fosaprepitant (focinvez), 1 mg
- J1435 — Injection, estrone, per 1 mg
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Next steps
- Run a reimbursement report for a device billed under J1438
- Watch J1438 for fee, coverage and descriptor changes
- Build a full Medicare revenue model for J1438
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.