HCPCS Code J3490

Official Description

Unclassified drugs

Short Descr	Drugs unclassified injection
Related Drugs	Aminocaproic Acid
Coverage	Special coverage instructions apply
Pricing Indicator(s)	51 – Drugs
MPI	A – Not applicable, as HCPCS priced under one methodology
MCM	2049
BETOS	O1E – Other drugs
TOS Code(s)	1 – Medical care
Added Date	1/1/1986
Status Code	Excluded from Physician Fee Schedule by Regulation
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	9 - Not Applicable
Multiple Procedures (51)	9 - Concept does not apply.
Bilateral Surgery (50)	9 - Concept does not apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	9 - Concept does not apply.
Co-Surgeons (62)	9 - Concept does not apply.
Team Surgery (66)	9 - Concept does not apply.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Items and Services Packaged into APC Rates
ASC Payment Indicator	Packaged service/item; no separate payment made.
MUE	Not applicable/unspecified.
MUE	Not applicable/unspecified.
IOM	100-02, 15, 50
OTS Orthotic	No
CCS Clinical Classification	240 - Medications (Injections, infusions and other forms)

JZ	Zero drug amount discarded/not administered to any patient
GY	Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
GA	Waiver of liability statement issued as required by payer policy, individual case
LT	Left side (used to identify procedures performed on the left side of the body)
BO	Orally administered nutrition, not by feeding tube
RT	Right side (used to identify procedures performed on the right side of the body)
KD	Drug or biological infused through dme
UD	Medicaid level of care 13, as defined by each state
JW	Drug amount discarded/not administered to any patient
GZ	Item or service expected to be denied as not reasonable and necessary
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GX	Notice of liability issued, voluntary under payer policy
50	Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
JA	Administered intravenously
TH	Obstetrical treatment/services, prenatal or postpartum
Q1	Routine clinical service provided in a clinical research study that is in an approved clinical research study
59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
76	Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
KX	Requirements specified in the medical policy have been met
77	Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
KQ	Second or subsequent drug of a multiple drug unit dose formulation
JB	Administered subcutaneously
GW	Service not related to the hospice patient's terminal condition
KP	First drug of a multiple drug unit dose formulation
SY	Persons who are in close contact with member of high-risk population (use only with codes for immunization)
X5	Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
25	Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59.
TB	Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes
GC	This service has been performed in part by a resident under the direction of a teaching physician
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
XS	Separate structure, a service that is distinct because it was performed on a separate organ/structure
CR	Catastrophe/disaster related
Q6	Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
EJ	Subsequent claims for a defined course of therapy, e.g., epo, sodium hyaluronate, infliximab
HB	Adult program, non geriatric
Q5	Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
SQ	Item ordered by home health
X2	Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services
24	Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period: the physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. this circumstance may be reported by adding modifier 24 to the appropriate level of e/m service.
51	Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
58	Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
79	Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
95	Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
99	Multiple modifiers: under certain circumstances 2 or more modifiers may be necessary to completely delineate a service. in such situations modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
AG	Primary physician
AM	Physician, team member service
AQ	Physician providing a service in an unlisted health professional shortage area (hpsa)
AY	Item or service furnished to an esrd patient that is not for the treatment of esrd
CA	Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission
CS	Cost-sharing waived for specified covid-19 testing-related services that result in and order for or administration of a covid-19 test and/or used for cost-sharing waived preventive services furnished via telehealth in rural health clinics and federally qualified health centers during the covid-19 public health emergency
F1	Left hand, second digit
F3	Left hand, fourth digit
F5	Right hand, thumb
F6	Right hand, second digit
F7	Right hand, third digit
F8	Right hand, fourth digit
FS	Split (or shared) evaluation and management visit
GP	Services delivered under an outpatient physical therapy plan of care
HD	Pregnant/parenting women's program
HH	Integrated mental health/substance abuse program
J2	Competitive acquisition program, restocking of emergency drugs after emergency administration
JD	Skin substitute not used as a graft
JK	One month supply or less of drug or biological
K0	Lower extremity prosthesis functional level 0 - does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.
KO	Single drug unit dose formulation
PD	Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
Q0	Investigational clinical service provided in a clinical research study that is in an approved clinical research study
SA	Nurse practitioner rendering service in collaboration with a physician
SS	Home infusion services provided in the infusion suite of the iv therapy provider
SV	Pharmaceuticals delivered to patient's home but not utilized
T5	Right foot, great toe
U5	Medicaid level of care 5, as defined by each state
U6	Medicaid level of care 6, as defined by each state
U8	Medicaid level of care 8, as defined by each state
UB	Medicaid level of care 11, as defined by each state
X1	Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care
X4	Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XP	Separate practitioner, a service that is distinct because it was performed by a different practitioner
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service