J7204 HCPCS code: Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu
J7204 is the HCPCS Level II code for injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu. In 2023 Medicare paid an average of $2.69 per service for J7204 across 2,044,235 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 19500 per day on outpatient hospital claims. In 2023, about 12 clinicians billed Medicare for J7204 for 14 beneficiaries.
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 | 2020-07-01 |
| Last action effective | 2020-07-01 |
Who bills J7204 (2023)
| Measure | Value |
|---|---|
| Clinicians billing (by place of service) | 12 |
| Medicare beneficiaries | 14 |
| States with claims | 0 |
Counts only. Supplier and clinician names, contact lists and state-by-state detail are in Caduvo.
Medicare utilization for J7204, 2023–2023
| Year | Services | Beneficiaries | Avg. allowed | Avg. paid |
|---|---|---|---|---|
| 2023 | 2,044,235 | 14 | $3.37 | $2.69 |
NCCI unit limits (MUE)
| Claim type | Max units per day | Rationale |
|---|---|---|
| outpatient hospital claims | 19500 | Prescribing Information |
| practitioner claims | 19500 | Prescribing Information |
Medicare policy articles for this code
- A56065: Billing and Coding: Guidance for Anti-Inhibitor Coagulant Complex (AICC) National Coverage Determination (NCD) 110.3 (Palmetto GBA (MAC - Part B))
Covered diagnoses (15 ICD-10-CM codes)
The diagnoses most often listed as covered in the policy articles above:
| ICD-10-CM | Diagnosis | Articles listing it |
|---|---|---|
| D66 | Hereditary factor VIII deficiency | 1 |
| D67 | Hereditary factor IX deficiency | 1 |
| D68.01 | Von Willebrand disease, type 1 | 1 |
| D68.020 | Von Willebrand disease, type 2A | 1 |
| D68.021 | Von Willebrand disease, type 2B | 1 |
| D68.022 | Von Willebrand disease, type 2M | 1 |
| D68.023 | Von Willebrand disease, type 2N | 1 |
| D68.03 | Von Willebrand disease, type 3 | 1 |
| D68.04 | Acquired von Willebrand disease | 1 |
| D68.09 | Other von Willebrand disease | 1 |
Showing 10 of 15. The full list, non-covered diagnoses and CSV export are in Caduvo.
What changed for J7204
- 2020-07-01: J7204 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 J7204?
J7204 is the HCPCS Level II code for injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu. Short descriptor: "Inj recombin esperoct per iu".
How much does Medicare pay for J7204?
In 2023, the average Medicare payment was $2.69 per service (average allowed $3.37).
Does Medicare cover J7204?
Coverage code C — Carrier judgment. Coverage is decided by the Medicare contractor (MAC) case by case.
Which diagnoses support coverage for J7204?
Medicare policy articles that cite J7204 list 15 covered ICD-10-CM diagnosis codes across 1 article. The most cited include D66 (Hereditary factor VIII deficiency), D67 (Hereditary factor IX deficiency), D68.01 (Von Willebrand disease, type 1). A listed diagnosis is necessary but not sufficient; the policy's other criteria still apply.
How many units of J7204 can be billed per day?
19500 on outpatient hospital claims; 19500 on practitioner claims (NCCI medically unlikely edits).
Related J72 codes
- J7200 — Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu
- J7201 — Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u.
- J7202 — Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u.
- J7203 — Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu
- J7205 — Injection, factor viii fc fusion protein (recombinant), per iu
- J7207 — Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u.
- J7208 — Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u.
- J7209 — Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u.
- J7210 — Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u.
- J7211 — Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 i.u.
- J7212 — Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgram
- J7213 — Injection, coagulation factor ix (recombinant), ixinity, 1 i.u.
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Next steps
- Run a reimbursement report for a device billed under J7204
- Watch J7204 for fee, coverage and descriptor changes
- Build a full Medicare revenue model for J7204
Sources: CMS HCPCS Level II release October 2025; 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.