Anchor HCPCS
J0289
AmBisome · per 10 mg
Phase 1
Identify what you're billing
Three drug classes, twelve products. The class drives the PA narrative; the formulation drives the J-code.
Landscape — the invasive fungal infection biller's view IDSA + FDA verified May 2026
Twelve IV antifungals across three drug classes. Patient population, infection class, and biomarker status drive the formulation choice — and the PA paperwork.
Invasive fungal infections cluster in three patient populations: profoundly immunocompromised hosts (AML induction, allogeneic HSCT, prolonged neutropenia, solid-organ transplant), critically ill ICU patients (central-line candidemia, COVID-associated pulmonary aspergillosis), and select community-acquired scenarios (cryptococcal meningitis in advanced HIV, endemic dimorphic infections). Pharmacy charges in this category are dominated by a small number of high-cost agents — liposomal amphotericin B (AmBisome, J0289) and the echinocandins — rather than by volume.
Therapy selection follows three patterns. Echinocandins (caspofungin J0637, micafungin J2248, anidulafungin J0348) are first-line empiric for invasive candidiasis and candidemia per IDSA 2016 candidiasis guidelines. Voriconazole IV (Vfend, J3465) is first-line for invasive aspergillosis per IDSA 2016 aspergillosis guidelines, with isavuconazonium (Cresemba) as the alternate first-line and the preferred option for hepatotoxicity or interaction concerns. Liposomal amphotericin B (AmBisome, J0289) is first-line for mucormycosis per IDSA 2019 mucormycosis guidelines, as salvage for refractory aspergillosis, and as induction for cryptococcal meningitis (with flucytosine). IV fluconazole (J1450) is reserved for documented fluconazole-susceptible isolates (most C. albicans, C. parapsilosis) and is the typical step-down agent.
ID consultation is the de facto gate for virtually every PA — both because the clinical decision is genuinely complex and because payers have learned that without ID involvement, broad-spectrum antifungals get continued past clinical need. Biomarker workup also drives both clinical decisions and PA approvals: serum galactomannan (CPT 87385) for aspergillosis, (1→3)-beta-D-glucan (CPT 87449) for invasive fungal screening, fungal blood culture, fungal PCR, and BAL/tissue specimens. Empiric therapy is appropriate while these are pending, but documentation of intent to obtain biomarker confirmation is expected. Step therapy applies in the cost-conscious direction: fluconazole before echinocandin for susceptible Candida, voriconazole before isavuconazonium for aspergillosis (in some plans), and avoidance of amphotericin in favor of echinocandins or azoles when clinically reasonable to spare nephrotoxicity. Ibrexafungerp (Brexafemme), the first oral triterpenoid, is mentioned for completeness but is oral-only and sits outside this IV rollup's billing scope.
Amphotericin formulation family — four distinct codes CMS HCPCS verified May 2026
Same active drug, four different products and four different J-codes. These cannot substitute on the claim form.
Amphotericin B is supplied in four FDA-approved IV formulations: liposomal (AmBisome), lipid complex (Abelcet), colloidal dispersion (Amphotec, largely off-market), and conventional deoxycholate (generic). They share an active drug and a broad-spectrum mechanism (ergosterol-binding polyene) but have distinct pharmacokinetics, nephrotoxicity profiles, indications, vial sizes, and per-mg costs. The codes are not interchangeable. The bedside MAR or pharmacy dispense record must reconcile to the J-code before claim submission.
| AmBisome (liposomal) | Abelcet (lipid complex) | Amphotec (colloidal) | Conventional (deoxycholate) | |
|---|---|---|---|---|
| HCPCS | J0289 | J0287 | J0288 | J0285 |
| HCPCS descriptor unit | per 10 mg | per 10 mg | per 10 mg | per 50 mg |
| Q2 2026 ASP+6% | $22.807 / 10 mg | $10.299 / 10 mg (Q4 2025 carry-fwd) | No active ASP entry (largely off-market) | $44.331 / 50 mg (~$0.89/mg) |
| Per-mg equivalent | ~$2.28 / mg | ~$1.03 / mg | n/a | ~$0.89 / mg |
| Vial | 50 mg lyophilized SDV | 100 mg / 20 mL SDV (5 mg/mL) | 50 mg, 100 mg lyophilized SDV | 50 mg lyophilized SDV |
| Typical dose | 3–5 mg/kg/day (up to 10 for mucor) | 5 mg/kg/day | 3–4 mg/kg/day | 0.3–1.5 mg/kg/day |
| Infusion time | ~2 hours | ~2 hours (rate 2.5 mg/kg/hr) | ~3–4 hours | ~2–6 hours (slower for tolerance) |
| Nephrotoxicity | Lowest of lipid formulations | Lower than conventional | Lower than conventional | Highest — AKI essentially universal |
| Manufacturer | Astellas Pharma US | Leadiant Biosciences (formerly Sigma-Tau / Enzon) | Ben Venue / discontinued / very limited US availability | Generic (X-Gen, others) |
| Primary indications | Mucor, salvage aspergillosis, crypto induction, broad empiric in IC host | Mostly used during AmBisome shortage | Niche / largely historical | Cryptococcosis (with flucytosine), select endemic mycoses, cost-constrained settings outside US |
Why so many formulations? The original amphotericin B deoxycholate is highly nephrotoxic
and produces severe infusion reactions (rigors, fever). The three lipid formulations were developed
decades later to mitigate nephrotoxicity. Liposomal (AmBisome) tolerates the highest doses safely and is
the only formulation with strong evidence in mucormycosis at 5–10 mg/kg/day. Lipid complex
(Abelcet) is functionally equivalent in many indications but is most often deployed when AmBisome is on
manufacturer shortage. Amphotec (colloidal dispersion) is essentially historical — many institutions
no longer stock it.
Common error: submitting J0289 units when conventional amphotericin (J0285) was actually
administered (or vice versa). The per-mg cost differs by ~2.5× and the audit risk is real. Reconcile
the pharmacy dispense record to the order set; the four amphotericin codes are mutually exclusive on a
given dose.
Per-drug dosing matrix FDA labels + IDSA guidelines verified May 2026
Twelve drugs, three classes. Dose, schedule, and HCPCS units side by side.
Amphotericin formulations
| Drug | HCPCS | Typical adult dose | Schedule | Bill units |
|---|---|---|---|---|
| AmBisome (liposomal ampho B) | J0289 (per 10 mg) | 3–5 mg/kg/day (up to 10 for mucor) | Once daily IV over ~2 hr | 70 kg × 3 mg = 210 mg = 21 units |
| Abelcet (lipid complex) | J0287 (per 10 mg) | 5 mg/kg/day | Once daily IV over ~2 hr (2.5 mg/kg/hr) | 70 kg × 5 mg = 350 mg = 35 units |
| Amphotec (colloidal) | J0288 (per 10 mg) | 3–4 mg/kg/day | Once daily IV over ~3–4 hr | 70 kg × 3 mg = 210 mg = 21 units |
| Amphotericin B deoxycholate (conventional) | J0285 (per 50 mg) | 0.3–1.5 mg/kg/day | Once daily IV over 2–6 hr (premedicate) | 70 kg × 1 mg = 70 mg = 2 units (round up partial) |
Echinocandins
| Drug | HCPCS | Typical adult dose | Schedule | Bill units |
|---|---|---|---|---|
| Cancidas (caspofungin) | J0637 (per 5 mg) | 70 mg load, then 50 mg/day (70 mg/day for >80 kg) | Once daily IV over ~1 hr | 50 mg = 10 units; 70 mg load = 14 units |
| Mycamine (micafungin) | J2248 (per 1 mg) | 100–150 mg/day for candidemia; 50 mg/day prophylaxis | Once daily IV over ~1 hr | 100 mg = 100 units |
| Eraxis (anidulafungin) | J0348 (per 1 mg) | 200 mg load, then 100 mg/day | Once daily IV over ~90 min (rate ≤1.1 mg/min) | 100 mg = 100 units; 200 mg load = 200 units |
Azoles
| Drug | HCPCS | Typical adult dose | Schedule | Bill units |
|---|---|---|---|---|
| IV fluconazole | J1450 (per 200 mg) | 800 mg load, then 400 mg/day (candidemia); 400 mg/day prophylaxis | Once daily IV over ~1–2 hr | 400 mg = 2 units; 800 mg load = 4 units |
| Vfend (voriconazole IV) | J3465 (per 10 mg) | 6 mg/kg q12h × 2 (load), then 4 mg/kg q12h | q12h IV over ≥1 hr (max rate 3 mg/kg/hr) | 70 kg × 4 mg = 280 mg = 28 units |
| Cresemba (isavuconazonium IV) | J1833 "Injection, isavuconazonium, 1 mg" (permanent) | 372 mg (equiv 200 mg isavuconazole) q8h × 6 doses (load), then 372 mg q24h | q8h then q24h IV over ≥1 hr | Bill mg of isavuconazonium administered (1 mg = 1 unit); document conversion to isavuconazole base in chart |
| Noxafil (posaconazole IV) | Verify MAC — commonly J3490 / J3590 unclassified | 300 mg q12h × 2 (load), then 300 mg/day | q12h then daily IV via central line (over ~90 min) | Bill mg of posaconazole administered; central line required for IV (peripheral causes thrombophlebitis) |
| Ibrexafungerp (Brexafemme) | Oral only | Out of IV scope | Pharmacy benefit | Not buy-and-bill |
Worked example — AmBisome induction for mucor (BW 70 kg, 5 mg/kg/day)
# Calculate dose
Dose: 5 mg/kg × 70 kg = 350 mg
Vials needed: 7 × 50 mg = 350 mg drawn (no waste)
# Drug claim line
J0289 · HCPCS unit = 10 mg · 350 mg / 10 = 35 units
Modifier: JZ (no waste — even multiple of 50 mg)
# Admin claim line
96365 · 1st hour therapeutic IV
96366 · +1 (2nd hour, ~2-hr total infusion)
# Drug reimbursement (Q2 2026)
35 units × $22.807 = $798.25 per daily dose (pre-sequestration)
Dose: 5 mg/kg × 70 kg = 350 mg
Vials needed: 7 × 50 mg = 350 mg drawn (no waste)
# Drug claim line
J0289 · HCPCS unit = 10 mg · 350 mg / 10 = 35 units
Modifier: JZ (no waste — even multiple of 50 mg)
# Admin claim line
96365 · 1st hour therapeutic IV
96366 · +1 (2nd hour, ~2-hr total infusion)
# Drug reimbursement (Q2 2026)
35 units × $22.807 = $798.25 per daily dose (pre-sequestration)
Worked example — Cancidas (caspofungin) candidemia (load + maintenance)
# Day 1 load
Caspofungin 70 mg IV — J0637 unit = 5 mg · 70 / 5 = 14 units
# Day 2+ maintenance
Caspofungin 50 mg IV daily — 50 / 5 = 10 units
# Day 1 reimbursement
14 units × $3.575 = $50.05
# Day 2+ daily reimbursement
10 units × $3.575 = $35.75 · 14-day course ≈ $514.85 total
Caspofungin 70 mg IV — J0637 unit = 5 mg · 70 / 5 = 14 units
# Day 2+ maintenance
Caspofungin 50 mg IV daily — 50 / 5 = 10 units
# Day 1 reimbursement
14 units × $3.575 = $50.05
# Day 2+ daily reimbursement
10 units × $3.575 = $35.75 · 14-day course ≈ $514.85 total
Per-drug NDC reference FDA NDC Directory verified May 2026
Representative carton-level NDCs. Verify against the actual pharmacy dispense record — many of these have generic versions with different NDCs.
| Drug | HCPCS | Representative NDC (11-digit) | Strength / vial | Manufacturer |
|---|---|---|---|---|
| AmBisome | J0289 | 0078-0444-61 | 50 mg lyophilized SDV | Astellas Pharma US |
| Abelcet | J0287 | 54482-0809-01 | 100 mg / 20 mL SDV (5 mg/mL) | Leadiant Biosciences |
| Amphotec | J0288 | Very limited US availability — verify at order time | 50 mg, 100 mg lyophilized SDV | Ben Venue / discontinued |
| Amphotericin B deoxycholate | J0285 | 39822-0220-05 (X-Gen) · generic versions also from Sandoz, Mylan | 50 mg lyophilized SDV | Generic (X-Gen, Sandoz, others) |
| Cancidas (caspofungin) | J0637 | 00006-3826-01 (50 mg) · 00006-3827-01 (70 mg) | 50 mg, 70 mg lyophilized SDV | Merck (originator); multiple generics |
| Mycamine (micafungin) | J2248 | 0469-3250-11 (50 mg) · 0469-3251-11 (100 mg) | 50 mg, 100 mg lyophilized SDV | Astellas (originator); multiple generics |
| Eraxis (anidulafungin) | J0348 | 0049-0114-28 (100 mg) | 100 mg lyophilized SDV (with diluent) | Pfizer (originator); generics now available |
| IV fluconazole | J1450 | 00338-1015-03 (Baxter 200 mg/100 mL bag) · multiple generics | 200 mg / 100 mL bag; 400 mg / 200 mL bag | Pfizer (Diflucan IV); multiple generics |
| Vfend IV (voriconazole) | J3465 | 00049-3170-28 (200 mg) | 200 mg lyophilized SDV | Pfizer (originator); multiple generics |
| Cresemba IV (isavuconazonium) | J1833 (1 mg = 1 unit) | 00469-0420-01 | 372 mg lyophilized SDV (equiv 200 mg isavuconazole base) | Astellas Pharma US |
| Noxafil IV (posaconazole) | J3490 / J3590 unclassified (verify MAC) | 00085-4331-01 | 300 mg / 16.7 mL SDV (18 mg/mL) | Merck |
Use carton-level NDC with N4 qualifier. Payers expect the 11-digit NDC in 24A shaded
area. Vial-level or 10-digit NDCs will trigger denials. Most echinocandins and azoles now have multiple
generic manufacturers — use the NDC of the actual product dispensed, not an originator NDC if a
generic was used.
Cresemba (isavuconazonium) IV: Bills under permanent HCPCS
J1833
"Injection, isavuconazonium, 1 mg" — 1 mg = 1 billing unit. A 372 mg loading dose = 372 units;
a 372 mg maintenance dose = 372 units. ASP appears on the CMS Part B Drug Pricing File; verify the
current quarter rate before posting.
Noxafil IV (posaconazole): No permanent J-code on the Q2 2026 CMS ASP file as of
this review. Most MACs accept
J3490 (unclassified non-self-administered drug) or
J3590 (unclassified biologic) with the brand and NDC listed in the narrative field of
the claim. Verify your MAC's current preference before submission — some have local C-codes
for HOPD outpatient claims.
Phase 2
Code the claim
Therapeutic IV admin codes (96365 + 96366) for all twelve drugs; long infusion times for amphotericin.
Administration codes CPT verified May 2026
All twelve IV antifungals use therapeutic IV admin codes — not chemotherapy admin codes.
| Code | Description | When to use |
|---|---|---|
96365 |
IV infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour | Primary code for all 12 antifungals. Bill once per encounter for the initial therapeutic IV infusion. |
96366 |
IV infusion, each additional hour (list separately) | For infusions exceeding 1 hour. Amphotericin formulations (2–6 hr), voriconazole IV (1–2 hr), Noxafil IV (~90 min) routinely trigger 96366. |
96367 |
IV infusion, additional sequential infusion of new drug/substance | When a second therapeutic IV drug is given sequentially (e.g., flucytosine PO is oral — not this code; but a sequential IV antibiotic on the same day would qualify). |
96374 |
IV push, single or initial substance/drug | Not appropriate for antifungals — all twelve are infused, not pushed. |
96413 / 96415 / 96417 |
Chemotherapy administration codes | Not appropriate for antifungals — these are non-chemotherapy therapeutic infusions. Use 96365/96366 instead. |
Flag long infusion times for amphotericin formulations. Conventional amphotericin
(J0285) is routinely infused over 4–6 hours for tolerance, generating 96365 + multiple units of
96366 (each additional hour). AmBisome (J0289) and Abelcet (J0287) at ~2 hours typically generate
96365 + 1 unit of 96366. Voriconazole IV (J3465) at ≥1 hr per dose, given q12h, generates two
96365 + 96366 sequences per day (each dose is a separate encounter / claim line).
Premedication for conventional amphotericin: If acetaminophen + diphenhydramine
± hydrocortisone premed is administered IV before conventional amphotericin (J0285) for infusion
reaction prevention, those drugs are separately billable under their own HCPCS / J-codes plus their own
admin codes (96374 IV push for diphenhydramine, etc.). Document the rationale (prior infusion reaction or
per institutional protocol).
Modifiers — JW / JZ per drug CMS verified May 2026
Most IV antifungals come in single-dose vials, so one of JZ or JW is required per CMS's July 2023 SDC policy.
| Drug | HCPCS | Vial type | Typical modifier | Notes |
|---|---|---|---|---|
| AmBisome | J0289 | 50 mg SDV | JW common (weight-based dosing rarely lands on 50 mg multiple) | One of JZ/JW required on every J0289 claim |
| Abelcet | J0287 | 100 mg / 20 mL SDV | JW common | 5 mg/kg weight-based dosing produces routine waste |
| Amphotec | J0288 | 50 mg, 100 mg SDV | JW or JZ | Verify at billing |
| Amphotericin B deoxycholate | J0285 | 50 mg SDV | JW common | Bill mg administered; partial-vial waste at low doses (0.3 mg/kg) |
| Cancidas (caspofungin) | J0637 | 50 mg + 70 mg SDV | JZ typical (doses are even multiples) | 50 mg dose = exactly 1 vial; 70 mg load = exactly 1 vial |
| Mycamine (micafungin) | J2248 | 50 mg + 100 mg SDV | JZ typical (100 mg dose = 1 vial) | JW only if partial vial used |
| Eraxis (anidulafungin) | J0348 | 100 mg SDV | JZ typical (100 mg or 200 mg dose) | Load = 2 vials, maintenance = 1 vial |
| IV fluconazole | J1450 | Premixed bag (multi-dose container) | JZ/JW may not apply — verify CMS SDC list | Premixed bags often outside SDC scope; document at billing time |
| Vfend IV (voriconazole) | J3465 | 200 mg SDV | JW common (weight-based, partial vials) | Bill mg administered (e.g., 280 mg = 28 units, JW 4 units waste = 320 mg drawn) |
| Cresemba IV (isavuconazonium) | J1833 (1 mg = 1 unit, permanent) | 372 mg SDV | JZ or JW required (single-dose vial) | JZ on administered; JW on any partial-vial waste |
| Noxafil IV (posaconazole) | J3490/J3590 | 300 mg / 16.7 mL SDV | Unclassified — verify MAC | JW/JZ may not apply to unclassified codes |
Worked example — AmBisome waste calculation (BW 65 kg, 5 mg/kg/day)
# Calculate dose
Dose: 5 mg/kg × 65 kg = 325 mg
Vials needed: 7 × 50 mg = 350 mg drawn
Discarded: 350 − 325 = 25 mg waste
# Drug claim lines (J0289 unit = 10 mg)
Line 1 (administered): J0289 · 325 mg / 10 = 33 units (round to billable units — verify MAC policy on fractional units)
Line 2 (waste): J0289 · 25 mg / 10 = 3 units · modifier JW
# Note on fractional units
Because J0289 unit = 10 mg, doses not divisible by 10 require rounding per MAC policy.
Some MACs allow decimal units (32.5 + 2.5); others round to whole units. Verify before billing.
Dose: 5 mg/kg × 65 kg = 325 mg
Vials needed: 7 × 50 mg = 350 mg drawn
Discarded: 350 − 325 = 25 mg waste
# Drug claim lines (J0289 unit = 10 mg)
Line 1 (administered): J0289 · 325 mg / 10 = 33 units (round to billable units — verify MAC policy on fractional units)
Line 2 (waste): J0289 · 25 mg / 10 = 3 units · modifier JW
# Note on fractional units
Because J0289 unit = 10 mg, doses not divisible by 10 require rounding per MAC policy.
Some MACs allow decimal units (32.5 + 2.5); others round to whole units. Verify before billing.
340B modifiers (JG, TB)
For 340B-acquired antifungals (common in hospital inpatient and HOPD settings for AmBisome, echinocandins), follow your MAC's current 340B reporting policy. Hospital outpatient claims under OPPS may require JG (340B-acquired drug) or TB depending on hospital category and CMS year-over-year rule changes. Update annually.
Modifier 25 — same-day E/M
Use modifier 25 on the E/M code when a significant, separately identifiable evaluation and management service is performed on the same day as the infusion. This is common for ID consult visits paired with the first IV antifungal dose — the ID consult is separately billable with modifier 25 on the E/M.
ICD-10-CM by infection FY2026 verified May 2026
Indication-driven. Pair the fungal infection code with the underlying immunocompromising condition (transplant, neutropenia, HIV) per payer expectations.
| Infection | ICD-10 | Notes |
|---|---|---|
| Candidemia / disseminated candidiasis | B37.7 | Most-billed candidiasis code; pair with sepsis (R65.2x), shock (R65.21), or organ-failure codes as documented |
| Candidal esophagitis | B37.81 | Common in advanced HIV (B20) and HSCT; supports IV echinocandin or fluconazole |
| Other candidiasis (urinary, skin, vulvovaginal, etc.) | B37.0–B37.6, B37.8x, B37.9 | Site-specific; verify against documentation |
| Invasive pulmonary aspergillosis | B44.0 | Voriconazole / isavuconazonium primary indication |
| Aspergillosis tonsillar / disseminated / other | B44.1 / B44.7 / B44.8 / B44.9 | Site-specific aspergillosis |
| Mucormycosis / zygomycosis | B46.0–B46.5 (specific sites) · B46.8 / B46.9 | AmBisome (J0289) + isavuconazonium primary; document tissue biopsy / fungal PCR |
| Cryptococcosis — pulmonary, meningitis, disseminated | B45.0 / B45.1 / B45.7 | AmBisome + flucytosine induction, fluconazole consolidation |
| PCP / PJP (Pneumocystis jirovecii pneumonia) | B59 | Primary therapy is TMP-SMX (not in this rollup); IV pentamidine or echinocandins as alternates in some scenarios |
| COVID-associated pulmonary aspergillosis (CAPA) | U07.1 + B44.0 + respiratory failure (J96.0x/J96.2x) | No dedicated CAPA code; bill combination |
| Candidemia in COVID-19 context | U07.1 + B37.7 | ICU-associated candidemia secondary to prolonged central lines and broad-spectrum antibiotics |
| Histoplasmosis / blastomycosis / coccidioidomycosis | B39.x / B40.x / B38.x | AmBisome induction for severe forms; itraconazole (oral) for consolidation in most cases |
| Sepsis with antifungal therapy | A41.9 + fungal code | Sepsis without identified organism plus the fungal infection code |
| Acquired immunodeficiency (HIV) | B20 | Pair with B37/B44/B45/B46 as the underlying immunocompromise condition; required for many PAs |
| Neutropenia | D70.x | Pair with the fungal code; common in AML induction and HSCT settings |
| Transplant status (organ / stem cell) | Z94.x (organ) · Z94.81 (bone marrow) | Document transplant status for prophylaxis or empiric therapy PAs |
Indication + immunocompromise pairing is the norm for PA. A B37.7 candidemia code alone
is often insufficient. Most payers want the immunocompromising condition (B20 HIV, D70.x neutropenia,
Z94.x transplant, or specific malignancy code) on the claim alongside the fungal infection code. This is
especially true for AmBisome, voriconazole, isavuconazonium, and posaconazole.
Site of care & place of service Verified May 2026
Three settings dominate: hospital inpatient for induction, HOPD / freestanding infusion for continuation, and home infusion / OPAT for prolonged courses.
| Setting | POS | Claim form | When it applies |
|---|---|---|---|
| Hospital inpatient | 21 | UB-04 / 837I (DRG-bundled) | Induction phase — AmBisome for mucor, echinocandin for septic candidemia, voriconazole for invasive aspergillosis. Drug bundled into DRG; not separately billable to Part B. |
| Hospital outpatient (on-campus) | 22 | UB-04 / 837I (OPPS) | Step-down infusion after inpatient discharge; some prolonged azole courses |
| Hospital outpatient (off-campus PBD) | 19 | UB-04 / 837I (site-neutral) | Same as POS 22 but post-section 603 site-neutral payment |
| Freestanding ambulatory infusion suite (AIC) | 49 | CMS-1500 / 837P | Preferred for OPAT by commercial UM; lower per-encounter cost than HOPD |
| Physician office | 11 | CMS-1500 / 837P | ID clinic-attached infusion; outpatient pediatric or adult infusion in specialty practice |
| Patient home | 12 | CMS-1500 + home infusion HCPCS | OPAT for prolonged azole or echinocandin courses — common for invasive aspergillosis (6–12 weeks) and osteomyelitis. Requires DME pump eligibility + ID-documented IV vs PO rationale. |
| ASC (rare) | 24 | CMS-1500 / 837P | Uncommon for antifungals — ASCs not typically equipped for multi-hour infusions |
Home infusion / OPAT economics: For a 6-week voriconazole IV course in invasive
aspergillosis, transition from hospital outpatient (POS 22) to home (POS 12) once the patient is
clinically stable can save thousands per week in facility fees. Home infusion bills S9494 (per diem
antibiotic/antifungal home infusion therapy) + the J3465 drug HCPCS + S9498 (nursing visit if needed).
Most patients transition to oral voriconazole when therapeutic troughs are achievable.
Inpatient DRG bundling. Drug acquisition cost for AmBisome (J0289) and the echinocandins
during the inpatient induction phase is bundled into the MS-DRG payment — the J-codes are not
separately billable to Part B for POS 21. The drug becomes separately billable only after discharge to
outpatient settings (POS 22/19/49/11/12).
Claim form field mapping Verified May 2026
CMS-1500 / 837P for office, AIC, and home infusion. UB-04 / 837I for hospital outpatient.
| Information | CMS-1500 box | Notes |
|---|---|---|
| NPI | 17b / 24J | Rendering provider |
| NDC qualifier + 11-digit NDC + UoM + qty | 24A shaded area | N4 + carton NDC + UN (units) or ML + total volume (e.g., N4 + 0078-0444-61 + UN + 7 for 7 vials of AmBisome 50 mg) |
| Drug HCPCS (J0289 / J0287 / J0285 / J0637 / etc.) | 24D | Per-drug HCPCS in mg-units of the HCPCS descriptor (10 mg for J0289, 5 mg for J0637, 1 mg for J2248, etc.) |
| Drug units | 24G | Use HCPCS descriptor unit. Example: 350 mg AmBisome dose = 35 units of J0289 (per 10 mg). |
| JW (waste) modifier line | 24D + 24G | Separate line for wasted units; required for SDV waste (AmBisome, Abelcet, voriconazole common) |
| JZ (no waste) modifier | 24D modifier slot | For SDC drugs when no waste occurred (caspofungin 50/70 mg, micafungin 100 mg, anidulafungin 100/200 mg are common JZ candidates) |
| CPT 96365 + 96366 (admin) | 24D (separate line) | 96365 (initial 1 hr) + 96366 × (additional hours). Amphotericin formulations routinely generate 96365 + 1–5 units of 96366. |
| ICD-10 | 21 | Fungal infection code + immunocompromise/underlying condition |
| PA number | 23 | Required by most commercial payers for AmBisome, echinocandins, broad-spectrum azoles; Medicare typically does not require PA but may require LCD-documented ID consult |
Unclassified codes (Cresemba, Noxafil IV): When using J3490 or J3590, include the
product name, NDC, dose in mg, and total cost in the narrative / remarks field (NTE segment for 837P, box
19 on CMS-1500). MACs will reject unclassified-code claims without narrative.
Phase 3
Get paid
ID consult + biomarker positivity + step therapy are the universal PA gates. Medicare ASP per drug below.
Payer policy snapshot Reviewed May 2026
PA criteria converge across payers: ID consult, biomarker workup, step therapy from less-expensive azoles to more-expensive echinocandins/amphotericin.
| Payer | Universal PA gates | Step therapy expectations | Notes |
|---|---|---|---|
| UnitedHealthcare Antifungal Medical Drug Policy |
ID consult documented; biomarker (galactomannan, BD-glucan, fungal culture/PCR) positive or pending; chart documentation of immunocompromise | Susceptible Candida: fluconazole step before echinocandin escalation. Suspected aspergillosis: voriconazole first-line before isavuconazonium. | AmBisome PA requires documented intolerance or contraindication to azole / echinocandin OR a mucor-specific indication. Site-of-care UM steers chronic infusion out of HOPD. |
| Aetna CPB + Medical Drug policies |
Aligned with IDSA candidiasis / aspergillosis / mucor guidelines; ID consult expected for prolonged courses | Yes — fluconazole step for susceptible Candida; voriconazole / isavuconazonium step before AmBisome for aspergillosis where clinically reasonable | Posaconazole prophylaxis (AML/HSCT) requires documented neutropenic risk per NCCN supportive care guidelines |
| BCBS plans Vary by plan |
Generally aligned with IDSA; some plans require ID telemedicine consult if on-site ID unavailable | Plan-specific; most have fluconazole-first step for Candida | Plans vary on Cresemba vs Vfend preference; document mucor or voriconazole intolerance for Cresemba |
| Medicare (Part B) LCDs by MAC |
No NCD for IV antifungals; MAC LCDs cover under FDA-approved indications + NCCN supportive care compendium support | No formal step therapy — clinical documentation of indication and immunocompromise drives coverage | Sequestration applies (~2% reduction). 340B reporting modifiers (JG/TB) for HOPD hospitals. |
Step therapy logic in detail
For invasive candidiasis or candidemia, IDSA 2016 candidiasis guidelines recommend echinocandin as first-line empiric, with step-down to fluconazole once a susceptible isolate is identified. Commercial payers generally accept this clinical pattern and do not require fluconazole as a first step before echinocandin in confirmed candidemia — but they do expect documentation of why empiric echinocandin is appropriate (septic / unstable patient, recent azole exposure, ICU acquisition).
For suspected or proven invasive aspergillosis, voriconazole IV is first-line per IDSA 2016 aspergillosis guidelines and most payers will approve directly. Isavuconazonium (Cresemba) requires either documented voriconazole intolerance, contraindicating drug interaction, hepatotoxicity, or a mucor differential diagnosis. AmBisome for aspergillosis is reserved for salvage or intolerance scenarios.
For mucormycosis, AmBisome at 5–10 mg/kg/day is first-line induction per IDSA 2019 mucormycosis guidelines — payers generally approve directly with documented tissue biopsy or fungal PCR. Isavuconazonium is the alternate first-line and the preferred consolidation oral step-down.
NCCN / IDSA compendium support
Antifungal coverage in oncology / transplant patients is supported by NCCN's Prevention and Treatment of Cancer-Related Infections (supportive care) guidelines and the IDSA guidelines cited above. Posaconazole prophylaxis for AML induction and HSCT is NCCN Category 2A. Voriconazole and isavuconazonium for invasive aspergillosis are IDSA strong recommendations.
Medicare reimbursement — per drug ASP table CMS Q2 2026 (live)
Quarterly ASP from CMS Part B Drug Pricing File. Refreshes automatically each quarter. Anchor (J0289) live-bound below.
Q2 2026 payment snapshot — anchor (J0289 AmBisome)
Effective April 1 – June 30, 2026 · Based on Q4 2025 ASP submissions
J0289 ASP + 6%
$22.807
per 10 mg / per unit
210 mg dose (3 mg/kg × 70 kg)
$478.95
21 units × $22.807
350 mg dose (5 mg/kg × 70 kg)
$798.25
35 units × $22.807
Per-drug Q2 2026 ASP+6% table
| Drug | HCPCS | HCPCS unit | ASP+6% per unit | Per-mg equivalent |
|---|---|---|---|---|
| AmBisome (liposomal) | J0289 | 10 mg | $22.807 | ~$2.28 / mg |
| Abelcet (lipid complex) | J0287 | 10 mg | $10.299 (Q4 2025 carry-fwd) | ~$1.03 / mg |
| Amphotec (colloidal) | J0288 | 10 mg | No active ASP entry | n/a |
| Amphotericin B deoxycholate | J0285 | 50 mg | $44.331 | ~$0.89 / mg |
| Cancidas (caspofungin) | J0637 | 5 mg | $3.575 | ~$0.72 / mg |
| Mycamine (micafungin) | J2248 | 1 mg | $0.255 | $0.26 / mg |
| Eraxis (anidulafungin) | J0348 | 1 mg | $0.487 | $0.49 / mg |
| IV fluconazole | J1450 | 200 mg | $3.874 | ~$0.02 / mg |
| Vfend IV (voriconazole) | J3465 | 10 mg | $0.652 | ~$0.07 / mg |
| Cresemba IV (isavuconazonium) | J1833 (1 mg) | ASP+6% per mg (verify current CMS file) | ~$5,000+ per daily dose at WAC (verify) | Permanent code — uses standard ASP-based reimbursement |
| Noxafil IV (posaconazole) | J3490/J3590 | Unclassified — AWP / WAC narrative | ~$300–$700 per 300 mg dose at WAC (verify) | n/a (unclassified) |
Sequestration: Approximately 2% reduction applies to actual paid amount, bringing
effective reimbursement to roughly ASP + 4.3% rather than ASP + 6%. Applies to all Part B drug payments
including all twelve antifungals in this rollup.
Next quarterly update: CMS publishes Q3 2026 ASP pricing effective July 1, 2026. CareCost
Estimate auto-rebinds the displayed values when the new file is released — no manual page update
required.
Coverage
No NCD specific to IV antifungals. Coverage falls under MAC LCDs for IV anti-infectives plus the FDA-approved indication framework. NCCN supportive care compendium support extends Medicare coverage for oncology / HSCT prophylaxis and treatment scenarios.
Patient assistance — manufacturer + foundation programs Verified May 2026
Foundation infectious-disease funds are smaller than oncology funds — verify open status frequently.
Manufacturer programs
- Astellas Patient Support — covers AmBisome (J0289), Mycamine (J2248), Cresemba IV: astellaspatientsupport.com · benefits investigation, PA support, copay assistance for commercially insured patients, free product for uninsured/underinsured meeting income criteria
- Pfizer Oncology Together / Pfizer RxPathways — covers Vfend IV (J3465), Eraxis (J0348): pfizerrxpathways.com · copay assistance, PAP for uninsured
- Merck Access Program / ACT (Activating Coverage Today) — covers Cancidas (J0637), Noxafil IV: merckaccessprogram.com · benefits investigation, PA support, copay assistance
- Gilead Advancing Access — historically supported AmBisome (now Astellas-distributed); legacy AmBisome inquiries may still route through Gilead in some channels
- Generic manufacturers (X-Gen, Sandoz, Mylan, others) for conventional amphotericin (J0285) and generic echinocandins: limited formal patient-assistance programs; payer copay accumulator/maximizer mitigation handled by infusion site financial counselor
Foundations
- PAN Foundation — panfoundation.org · has periodically opened Invasive Fungal Infections and Aspergillosis funds; verify current status
- HealthWell Foundation — healthwellfoundation.org · antifungal funds open/close throughout the year for selected conditions (cryptococcal meningitis, invasive aspergillosis)
- Good Days — mygooddays.org · periodically supports rare and severe infections
- NeedyMeds — needymeds.org · aggregator for manufacturer PAPs and disease-specific funds
Need to model what a specific patient will actually pay after copay assistance, deductible, coinsurance,
and OOP max for a multi-week IV antifungal course? Run a CareCost Estimate
— J0289 AmBisome (anchor) pre-loaded.
Phase 4
Fix problems
Missing ID consult, absent biomarker positivity, step therapy skip, nephrotoxicity not monitored, duration not justified.
Top 5 denials & how to fix them Verified May 2026
| # | Denial reason | Common cause | Fix |
|---|---|---|---|
| 1 | No ID consult documented | PA submitted with order set or hospitalist note only — no formal ID consult attached | Attach the ID consult note (not just an order). Telemedicine ID consults are widely accepted when on-site ID is unavailable. Address ID engagement explicitly in the PA narrative. |
| 2 | No biomarker positivity (galactomannan, BD-glucan, fungal culture/PCR) | Empiric therapy started, biomarker workup not yet sent or pending without follow-up | Submit pending biomarker labs in the PA. If positive results are available, attach the lab report. Document the clinical pre-test probability supporting empiric coverage while workup is pending. |
| 3 | Step therapy not satisfied | AmBisome or echinocandin requested without prior fluconazole trial (when fluconazole would have been clinically reasonable) | Document why step therapy was bypassed: severity (sepsis, hemodynamic instability), recent azole exposure, prior fluconazole failure, isolate resistance, drug interaction, mucor differential. Cite IDSA guidelines. |
| 4 | Nephrotoxicity / labs not monitored (amphotericin formulations) | Continuation PA submitted without serial creatinine, electrolyte (K+, Mg++), or LFT documentation | Submit the lab trend (baseline + every 2–3 days during therapy). Document any creatinine bump, potassium/magnesium replacement, or formulation switch (e.g., switched from conventional J0285 to AmBisome J0289 for nephrotoxicity). |
| 5 | Duration of therapy not justified | Continuation PA submitted without clinical rationale beyond the typical 14–42 day course | Cite IDSA duration guidance for the specific indication: candidemia 14 days after first negative blood culture, invasive aspergillosis 6–12 weeks minimum, mucor longer per source control, cryptococcal consolidation 8 weeks fluconazole after AmBisome induction. Document clinical and biomarker response trends. |
| + | Unclassified code (Cresemba / Noxafil IV) rejected | J3490 / J3590 submitted without product narrative | Add product name, NDC, dose in mg, and total cost to NTE segment / box 19 narrative. Verify MAC's specific narrative format requirements. |
| + | JZ/JW missing on SDV drug | Single-dose container modifier policy not applied to J0289 / J0287 / J3465 / J0637 / J2248 / J0348 SDV claims | Add JZ (no waste) or JW (waste line) per CMS SDC policy. Premixed bag drugs like IV fluconazole (J1450) may be outside SDC scope — verify the CMS SDC list at billing time. |
| + | Wrong amphotericin J-code (J0289 vs J0287 vs J0285) | Formulation administered does not match claim | Reconcile pharmacy dispense record to order. The four amphotericin codes are mutually exclusive on a given dose and have ~2.5× per-mg cost spread. |
| + | Site of care (HOPD) for chronic infusion | HOPD administration on commercial plan with site-of-care UM for a stable patient | Move to freestanding AIC (POS 49), office (POS 11), or home (POS 12). Submit medical-necessity letter if HOPD required for clinical complexity (HSCT day-100, severe co-morbidities). |
The denial story is consistent across payers. ID consult + biomarker workup + step
therapy logic + monitoring documentation + duration rationale — if all five are in the chart and the
PA narrative, denials are uncommon. Front-load these into the original PA submission rather than waiting
to address them at appeal.
Frequently asked questions Verified May 2026
Liposomal vs lipid complex vs conventional amphotericin — what's the cost difference?
All three are billed separately and are NOT interchangeable. Liposomal amphotericin B (AmBisome, J0289) is by far the highest-cost formulation at $22.807 per 10 mg (Q2 2026 ASP+6%) and is the first-line lipid formulation for nephrotoxicity-prone patients and mucormycosis. Lipid complex (Abelcet, J0287) is $10.299 per 10 mg and is mostly used when AmBisome is on shortage. Conventional amphotericin B deoxycholate (J0285) is $44.331 per 50 mg — about $0.89/mg, an order of magnitude cheaper than liposomal — but is reserved for select indications because of severe nephrotoxicity and infusion reactions.
How do I pick between caspofungin, micafungin, and anidulafungin?
All three echinocandins (J0637 caspofungin, J2248 micafungin, J0348 anidulafungin) have equivalent IDSA recommendations as first-line for invasive candidiasis and candidemia. Selection is usually driven by formulary, drug-interaction profile, and renal/hepatic function rather than billing. Caspofungin requires hepatic dose adjustment (Child-Pugh B reduction); micafungin and anidulafungin do not need dose adjustment for hepatic or renal impairment. Anidulafungin has the cleanest drug-interaction profile (no CYP metabolism, no P-gp).
When do payers want an azole vs an echinocandin?
For invasive candidiasis or candidemia, most commercial payers and CMS LCDs expect echinocandin as first-line empiric per IDSA 2016 candidiasis guidelines; step-down to oral fluconazole is appropriate once the isolate is identified as fluconazole-susceptible. For invasive aspergillosis, voriconazole IV (J3465) is first-line per IDSA 2016 aspergillosis guidelines; isavuconazonium (Cresemba) is the alternate. Posaconazole IV (Noxafil) is prophylaxis-focused for AML/HSCT and a salvage option for mucor.
When is Cresemba (isavuconazonium) the right choice for mucor?
Per IDSA 2019 mucormycosis guidelines, liposomal amphotericin B (AmBisome, J0289) remains first-line
induction at 5–10 mg/kg/day. Isavuconazonium (Cresemba) is the alternate first-line and the
preferred step-down/consolidation oral when source control is achieved. Cresemba IV bills under
permanent J1833 "Injection, isavuconazonium, 1 mg" (verify your MAC's current rate
assignment).
Can I bill galactomannan and BD-glucan testing?
Yes — serum galactomannan EIA (CPT 87385) and (1→3)-beta-D-glucan (CPT
87449 or unlisted micro 87999, MAC-dependent) are separately billable when
ordered for aspergillosis screening or invasive fungal disease workup. Payers expect documentation of
immunocompromised status and a clinical scenario where positivity meaningfully changes therapy.
When do I step down to oral therapy?
Per IDSA, step-down to oral is appropriate when the patient is clinically improving, hemodynamically stable, tolerating oral intake, and the isolate is susceptible to an available oral agent. Common transitions: echinocandin to oral fluconazole for C. albicans/parapsilosis candidemia after 5–7 days; voriconazole IV to PO at therapeutic trough; isavuconazonium IV to PO (same molecule).
Are prophylaxis and treatment dosing different?
Yes. Posaconazole prophylaxis for AML/HSCT is 300 mg IV daily after a 300 mg q12h × 2 loading day; treatment uses the same dose for longer durations. Fluconazole prophylaxis is 400 mg IV daily; treatment of candidemia is 800 mg load then 400 mg daily. Voriconazole treatment is 6 mg/kg IV q12h × 2 doses then 4 mg/kg q12h; there is no FDA-approved IV prophylaxis dose.
How does COVID-associated pulmonary aspergillosis (CAPA) bill?
There is no dedicated ICD-10 code for CAPA. Bill U07.1 (COVID-19) plus B44.0
(invasive pulmonary aspergillosis) plus the appropriate respiratory failure code (J96.0x or
J96.2x). Voriconazole IV (J3465) and isavuconazonium are the antifungals of record. Document
galactomannan or BAL aspergillus positivity in the chart for PA.
Any pediatric dosing notes?
AmBisome (J0289) is weight-based at 3–5 mg/kg/day (up to 10 for mucor). Caspofungin is 70 mg/m² load then 50 mg/m² daily (BSA-based in peds). Micafungin is 2–4 mg/kg/day; anidulafungin is 3 mg/kg load then 1.5 mg/kg daily. Fluconazole is 12 mg/kg/day for invasive infection. Voriconazole peds dosing differs from adults (8 mg/kg IV q12h × 2 then 8 mg/kg q12h for ages 2–12) and requires aggressive therapeutic drug monitoring.
Is home infusion realistic for prolonged azole therapy?
Yes — voriconazole, fluconazole, micafungin, and AmBisome are all routinely run via OPAT once the
patient is stable. Home infusion under Medicare Part B requires DME-route eligibility and ID-consult
documentation supporting need for IV vs PO. Commercial home infusion uses S9494 (per diem)
plus the drug HCPCS plus nursing visit codes (S9498).
Is ibrexafungerp (Brexafemme) part of this rollup?
Only by mention. Ibrexafungerp (Brexafemme) is the first oral triterpenoid antifungal and is approved for vulvovaginal candidiasis (oral tablets only). There is no IV ibrexafungerp formulation as of May 2026 and no buy-and-bill HCPCS J-code applicable to this rollup.
Reference
Sources & methodology
Every claim on this page is sourced. Methodology and review history below.
Source documents
- IDSA — Clinical Practice Guideline for the Management of Candidiasis (2016 update)
- IDSA — Practice Guideline for the Diagnosis and Management of Aspergillosis (2016)
- IDSA / ECMM — Global Guideline for the Diagnosis and Management of Mucormycosis (2019)
- FDA Drug Approvals and Databases (Drugs@FDA) — AmBisome, Abelcet, Cancidas, Mycamine, Eraxis, Vfend, Cresemba, Noxafil labels
- DailyMed — current labels for all rollup drugs (NDC, package insert, dosing)
- CMS — Medicare Part B Drug ASP Pricing File
- CMS — Local Coverage Determinations (LCDs) by MAC for IV anti-infective therapy
- NCCN — Prevention and Treatment of Cancer-Related Infections (Supportive Care)
- UnitedHealthcare — Medical Drug Policies (antifungal coverage)
- Aetna Clinical Policy Bulletins — Antifungal agents
- FDA National Drug Code Directory
- CMS — JW/JZ modifier policy (CR 12056, eff. July 2023)
- CMS HCPCS Level II Quarterly Updates
- Individual manufacturer access programs: Astellas Patient Support, Pfizer RxPathways, Merck Access Program
About this page
We maintain this page as a living rollup reference for invasive-fungal IV billing. Medicare ASP pricing for the anchor (J0289) is bound to our underlying CareCost data layer and refreshes automatically when CMS publishes new quarterly files. The per-drug ASP table is updated quarterly. Coding and policy content is reviewed at least semi-annually and updated whenever a source document changes.
Found an error? Email hello@carecostestimate.com.
Refresh cadence
| Element | Cadence | How it's refreshed |
|---|---|---|
| Medicare ASP pricing (anchor J0289) | Quarterly | Auto-bound to CareCost ASP layer; updates on CMS file release. |
| Per-drug ASP table | Quarterly | Manual page refresh against the CMS Part B Drug Pricing File. |
| IDSA / NCCN guidelines | Event-driven | Refreshed when society publishes a guideline update. |
| Payer policies (UHC, Aetna, BCBS) | Semi-annual | Manual review against published payer policy documents. |
| HCPCS / CPT / modifier rules | Annual | Reviewed against CMS HCPCS quarterly files and AMA CPT releases. |
| NDC, dosing, FDA labels | Event-driven | Tied to FDA label revision dates. |
Reviewer
Pending SME review. This page is staff-authored from primary sources (FDA labels, CMS
ASP Q2 2026, IDSA guidelines, payer policy documents — all linked above). Editorial review by an
infectious-disease pharmacist or ID physician is in progress. Until that review is complete, treat this
as a draft rollup reference and verify each cited source for high-stakes claims, particularly the
permanent J-code mapping for Cresemba (J1833) and the unclassified-code path for Noxafil IV.
Change log
- — Initial publication. Wave 8 commodity rollup. ASP data: Q2 2026 (anchor J0289). Sources: IDSA candidiasis 2016, aspergillosis 2016, mucor 2019; FDA labels; CMS Part B ASP; UHC/Aetna antifungal medical drug policies. Twelve drugs covered: AmBisome (J0289), Abelcet (J0287), Amphotec (J0288), conventional amphotericin (J0285), Cancidas (J0637), Mycamine (J2248), Eraxis (J0348), IV fluconazole (J1450), Vfend IV (J3465), Cresemba IV (unclassified), Noxafil IV (unclassified). Brexafemme/ibrexafungerp mentioned but out of IV scope.
Methodology
Every claim on this page is sourced inline. Anchor (J0289) ASP pricing reflects the current CMS Part B Drug ASP Pricing File. Per-drug ASP values are read directly from the same file for the most recent quarter present. Payer policies are read directly from each payer's published medical/pharmacy policy documents. IDSA guideline citations reference the most recent published updates. Indication mapping is verified against the current FDA labels.