Anchor HCPCS
J0133
Acyclovir, 5 mg / unit
Phase 1
Identify what you're billing
The agent, the indication, the transplant context, and whether a permanent J-code applies all matter before you post.
About this IV antiviral rollup IDSA / AST / ASTCT 2025 verified May 2026
When IV antivirals are needed, why the class is dominated by transplant medicine, and what makes the billing different from other infusion-clinic drugs.
Most antiviral therapy outside HIV is oral — valacyclovir, valganciclovir, oseltamivir, nirmatrelvir/ritonavir.
The IV antiviral class exists for three narrow but high-acuity use cases. First, biomarker-driven CMV
management in transplant recipients: allogeneic HSCT recipients and high-risk solid organ transplant
patients (kidney, lung, heart, liver) are monitored with serial CMV PCR (quantitative viral load) and treated
when viremia crosses an institution-specific threshold (commonly 1,000-10,000 IU/mL depending on transplant
type and immunosuppression intensity). Ganciclovir IV (J1570) is the first-line induction agent;
when ganciclovir-resistant or failing, foscarnet (J1455) or cidofovir (J0740) are
used as salvage. Newer agents (letermovir / Prevymis for HSCT prophylaxis; maribavir / Livtencity for
refractory CMV) extend the toolkit.
Second, severe HSV disease. IV acyclovir 10 mg/kg q8h is the standard for HSV encephalitis, neonatal HSV (CNS or disseminated), and severe HSV in immunocompromised patients. HSV PCR (CSF or tissue) documentation supports medical necessity for the IV regimen rather than oral valacyclovir. The 14-21 day course commonly produces substantial vial-waste billing under JW because of the weight-based dosing.
Third, severe disseminated VZV. IV acyclovir is reserved for VZV with visceral involvement, ophthalmic complications, CNS involvement, or in immunocompromised hosts with extensive cutaneous disease. Routine immunocompetent adult shingles is oral therapy and will be denied if billed as outpatient IV.
Transplant populations dominate the inpatient and HOPD volume. Many of these drugs are induced in the inpatient setting (DRG-bundled for Medicare admissions) and consolidated to HOPD or home infusion for maintenance (separately payable). Nephrotoxicity is the dominant safety concern across the class: acyclovir IV crystallizes in renal tubules without adequate hydration; ganciclovir causes myelosuppression and renal dose adjustment; foscarnet carries an FDA boxed warning for renal impairment and chelates calcium/magnesium/phosphate/potassium requiring electrolyte repletion; cidofovir carries an FDA boxed warning for renal toxicity and requires mandatory probenecid pre/post-medication plus pre-hydration. Documentation of renal monitoring is part of the medical necessity record and a frequent denial trigger when absent.
CMV-specific drug family — how to choose AST / ASTCT 2025 verified May 2026
Four agents target CMV in transplant. They are NOT interchangeable; each has a distinct role and step-therapy position.
Ganciclovir J1570 |
Foscarnet J1455 |
Cidofovir J0740 |
Letermovir (no perm J-code) | Maribavir (oral only) | |
|---|---|---|---|---|---|
| Brand & manufacturer | Generic (Cytovene historical, Roche) | Generic (Foscavir historical) | Vistide (Gilead) | Prevymis (Merck) | Livtencity (Takeda) |
| Role | First-line CMV induction & treatment | Salvage when ganciclovir resistant or failing | Salvage (CMV retinitis HIV; BK virus off-label) | Prophylaxis only (HSCT / kidney transplant) | Refractory CMV after step failure |
| Route | IV (1 hr infusion) | IV (continuous over 1-2 hr, q8h or q12h) | IV (1 hr infusion) + probenecid pre/post | IV (1 hr) or oral 240 / 480 mg daily | Oral 200 mg BID |
| Mechanism | Nucleoside analog; viral DNA pol | Pyrophosphate analog; DNA pol | Nucleotide analog; DNA pol | CMV terminase complex inhibitor | UL97 kinase inhibitor |
| Key toxicity | Myelosuppression (neutropenia) | Nephrotoxicity (boxed); electrolytes | Nephrotoxicity (boxed); ocular | Generally well tolerated; nausea | Taste disturbance; nausea |
| Medicare benefit | Part B medical (J-code) | Part B medical (J-code) | Part B medical (J-code) | IV via J3490 + invoice; oral Part D | Part D pharmacy |
| Step therapy in 2026 | None (front-line) | After ganciclovir failure / resistance | After ganciclovir + foscarnet failure | HSCT-prophylaxis indication only | Documented failure of 2+ standard agents |
Common confusion: Prevymis is prophylaxis (prevents reactivation in HSCT recipients
through day 100 or extended to day 200) — not a treatment for active CMV disease. Switching a CMV-treatment
patient onto Prevymis to "spare nephrotoxicity from foscarnet" is off-label and will be denied. Livtencity is
for refractory CMV treatment after standard agents have failed; using it earlier in the step ladder will also
be denied.
Acyclovir & HSV / VZV family is handled separately on this page (see
dosing matrix and ICD-10 section) because the indication and
billing pattern are distinct from CMV. The RSV monoclonals (Synagis, Beyfortus) are detailed in
admin codes — they are IM and use CPT 96372, not 96365.
Dosing by drug & indication FDA labels + IDSA / AST guidelines verified May 2026
Per FDA prescribing information for each agent and IDSA / AST / ASTCT transplant infectious disease guidelines.
Per-drug dosing matrix
| Drug (HCPCS) | Indication | Adult induction / treatment | Maintenance / prophylaxis | Renal adjust? |
|---|---|---|---|---|
AcyclovirJ0133 (5 mg / unit) |
HSV encephalitis | 10 mg/kg IV q8h × 14-21 days, infused over ≥1 hr | n/a (acute course) | Yes — CrCl based |
| Neonatal HSV (CNS / disseminated) | 20 mg/kg IV q8h × 14-21 days | Oral suppression 300 mg/m² PO TID × 6 mo (off-label) | Yes | |
| Severe VZV (immunocompromised, dissem, CNS) | 10 mg/kg IV q8h × 7-10 days (then PO step) | Step to oral valacyclovir 1 g TID when stable | Yes | |
GanciclovirJ1570 (500 mg / unit) |
CMV induction (transplant) | 5 mg/kg IV q12h × 14-21 days (or until two consecutive negative PCRs) | 5 mg/kg IV daily, or step to oral valganciclovir 900 mg BID induction / daily maintenance | Yes — CrCl based |
| Pre-emptive therapy (transplant viremia) | 5 mg/kg IV q12h until viremia clears | Step to oral valganciclovir | Yes | |
FoscarnetJ1455 (1,000 mg / unit) |
CMV induction (ganciclovir-resistant or refractory) | 60 mg/kg IV q8h or 90 mg/kg IV q12h × 14-21 days, infused over ≥1-2 hr | 90-120 mg/kg IV daily maintenance | Yes — CrCl-based mandatory; pre-hydration 500-1,000 mL NS |
| Acyclovir-resistant HSV (immunocompromised) | 40 mg/kg IV q8-12h until lesions heal | n/a | Yes | |
CidofovirJ0740 (375 mg / unit) |
CMV retinitis (HIV; FDA on-label) | 5 mg/kg IV once weekly × 2 weeks (induction) | 5 mg/kg IV every 2 weeks; probenecid 2 g PO 3 hr pre-dose, then 1 g PO at 2 and 8 hr post; pre-hydration 1 L NS | Yes — CrCl-based; contraindicated CrCl < 55 or proteinuria |
| BK virus nephropathy (off-label HSCT / kidney tx) | 0.25-1 mg/kg IV every 1-2 weeks (low-dose, often without probenecid) | Continue based on viremia / viruria | Mandatory monitoring | |
Letermovir IVJ3490 unclassified |
CMV prophylaxis (HSCT) | 480 mg IV once daily (or 240 mg if on cyclosporine) | Continued through day 100 post-HSCT (or day 200 high-risk) | No standard adjust; avoid in severe hepatic impairment |
| CMV prophylaxis (kidney transplant high-risk D+/R-) | 480 mg IV / PO once daily | Continued through ~6 months post-transplant per label | No | |
| Maribavir (oral only) | Refractory post-transplant CMV | 400 mg PO BID × 8 weeks (no IV form) | Continue through clearance + 2 weeks | No renal; hepatic monitor |
Palivizumab90378 (50 mg / unit, IM) |
RSV prophylaxis (high-risk infants) | 15 mg/kg IM once monthly during RSV season (max 5 doses) | n/a (seasonal) | No |
Nirsevimab90380 / 90381 (50 mg, IM) |
RSV prophylaxis (all infants entering first season) | Single IM dose: 50 mg if < 5 kg / 100 mg if ≥ 5 kg / 200 mg if entering 2nd season high-risk | n/a (single dose) | No |
Worked example — HSV encephalitis, 70 kg adult, 14-day course
# Per-dose calculation
10 mg/kg × 70 kg = 700 mg per dose
q8h dosing = 3 doses/day × 14 days = 42 doses total
Total mg = 700 mg × 42 = 29,400 mg total
Total J0133 units = 29,400 / 5 = 5,880 units J0133
# Vial draw (using 1,000 mg single-dose vials)
700 mg from 1,000 mg vial → 300 mg discarded per dose
Total discarded = 300 × 42 = 12,600 mg = 2,520 units JW per course
# Drug reimbursement at Q2 2026 ASP+6%
5,880 units × $0.017 = $99.96 (administered drug)
2,520 units × $0.017 = $42.84 (waste, JW line)
# Acyclovir generic is inexpensive; admin labor and inpatient bed days dominate the encounter economics.
10 mg/kg × 70 kg = 700 mg per dose
q8h dosing = 3 doses/day × 14 days = 42 doses total
Total mg = 700 mg × 42 = 29,400 mg total
Total J0133 units = 29,400 / 5 = 5,880 units J0133
# Vial draw (using 1,000 mg single-dose vials)
700 mg from 1,000 mg vial → 300 mg discarded per dose
Total discarded = 300 × 42 = 12,600 mg = 2,520 units JW per course
# Drug reimbursement at Q2 2026 ASP+6%
5,880 units × $0.017 = $99.96 (administered drug)
2,520 units × $0.017 = $42.84 (waste, JW line)
# Acyclovir generic is inexpensive; admin labor and inpatient bed days dominate the encounter economics.
Worked example — CMV induction, 70 kg HSCT recipient, 14-day course
# Ganciclovir per-dose calculation
5 mg/kg × 70 kg = 350 mg per dose
q12h dosing = 2 doses/day × 14 days = 28 doses total
Total mg = 350 mg × 28 = 9,800 mg total
Total J1570 units = 9,800 / 500 = 19.6 units → bill 20 units rounded up
# Vial draw (500 mg single-dose vials)
350 mg from 500 mg vial → 150 mg discarded per dose
Waste = 150 / 500 = 0.3 units per dose → round up per claim
# Drug reimbursement at Q2 2026 ASP+6%
20 units × $34.047 = $680.94 (administered drug)
# Inpatient encounter: DRG-bundled, J1570 not separately payable to hospital.
# Outpatient consolidation in HOPD: separately payable at ASP+6%.
5 mg/kg × 70 kg = 350 mg per dose
q12h dosing = 2 doses/day × 14 days = 28 doses total
Total mg = 350 mg × 28 = 9,800 mg total
Total J1570 units = 9,800 / 500 = 19.6 units → bill 20 units rounded up
# Vial draw (500 mg single-dose vials)
350 mg from 500 mg vial → 150 mg discarded per dose
Waste = 150 / 500 = 0.3 units per dose → round up per claim
# Drug reimbursement at Q2 2026 ASP+6%
20 units × $34.047 = $680.94 (administered drug)
# Inpatient encounter: DRG-bundled, J1570 not separately payable to hospital.
# Outpatient consolidation in HOPD: separately payable at ASP+6%.
Renal dosing reductions apply to all four core agents. Acyclovir, ganciclovir, and foscarnet
require CrCl-based dose reductions per their FDA labels. Cidofovir is contraindicated at CrCl < 55 mL/min.
Document CrCl at baseline and at each dose for audit defense and payer-policy compliance.
NDC reference (per drug) FDA NDC Directory verified May 2026
Sample representative NDCs from major U.S. manufacturers. Multiple generics exist for acyclovir, ganciclovir, and foscarnet — confirm the specific NDC in pharmacy stock before posting.
| Drug / HCPCS | NDC (representative) | Strength | Package | Units/vial |
|---|---|---|---|---|
Acyclovir · J0133 |
00173-0992-93 (GSK historical) / 0143-9509-01 (Hikma) / 00409-7615-01 (Hospira/Pfizer) |
500 mg lyophilized SDV | 10 vials / carton (varies) | 100 units (5 mg = 1 unit) |
0143-9510-01 (Hikma) |
1,000 mg lyophilized SDV | 10 vials / carton | 200 units | |
Ganciclovir · J1570 |
00007-4805-01 (GSK historical Cytovene) / 00781-3260-95 (Sandoz generic) / 16729-228-25 (Accord) |
500 mg lyophilized SDV | 1 vial / carton (single-dose) | 1 unit (500 mg = 1 unit) |
Foscarnet · J1455 |
00074-2034-04 (Hospira/Pfizer Foscavir historical) / 00409-8050-04 (Hospira/Pfizer generic) |
24 mg/mL solution; 250 mL or 500 mL bottle (6,000 or 12,000 mg) | 10 bottles / case | 6 or 12 units (1,000 mg = 1 unit) |
Cidofovir · J0740 |
61958-0301-1 (Gilead Vistide) |
75 mg/mL; 5 mL SDV (375 mg) | 1 vial / carton | 1 unit (375 mg = 1 unit) |
Letermovir IV · J3490 |
00006-3956-01 (Merck Prevymis IV; 240 mg) / 00006-3958-01 (480 mg) |
240 or 480 mg in 12 / 24 mL solution SDV | 1 vial / carton | Bill J3490 with NDC + invoice |
Palivizumab · 90378 |
60574-4111-1 (Sobi Synagis; 50 mg) / 60574-4114-1 (100 mg) |
50 mg / 0.5 mL or 100 mg / 1 mL solution SDV | 1 vial / carton | 1 unit per 50 mg |
Nirsevimab · 90380 / 90381 |
49281-0573-15 (Sanofi Beyfortus 50 mg) / 49281-0574-15 (100 mg) / 49281-0575-15 (200 mg) |
50 mg / 0.5 mL, 100 mg / 1 mL, or 200 mg / 2 mL solution prefilled syringe | 1 syringe / carton | Per CPT code (weight-based) |
Use 11-digit NDC with N4 qualifier in 24A shaded area. Most of these drugs are multi-source
generics and the NDC you bill must match the specific manufacturer dispensed by pharmacy — the
representative NDCs above are examples, not the complete list. Confirm the actual NDC from the vial /
syringe before posting. For letermovir IV the unclassified J3490 line requires the NDC + manufacturer
invoice for payer review.
Phase 2
Code the claim
Therapeutic IV admin codes for the four core agents; CPT 96372 for the IM RSV monoclonals; transplant T86.x is the deciding ICD-10 layer.
Administration codes CPT 2026 verified May 2026
All four core IV antivirals are non-chemotherapy therapeutic IV infusions. RSV monoclonals are IM injections under CPT 96372.
| CPT | Description | When to use |
|---|---|---|
96365 |
Intravenous infusion, therapeutic / prophylactic / diagnostic; initial, up to 1 hour | Primary admin code for acyclovir, ganciclovir, foscarnet (first hr), cidofovir, letermovir IV. Bill once per encounter as initial therapeutic infusion. |
96366 |
IV infusion, each additional hour (List separately) | For foscarnet (typical 1-2 hr per dose), cidofovir + probenecid pre-hydration (extends total chair time), pediatric slow-rate infusions. Add to 96365. |
96367 |
Additional sequential infusion of new drug / substance, up to 1 hour | When a second therapeutic drug (e.g., concurrent IVIG, separate antibiotic) is infused sequentially through the same access on the same encounter. |
96372 |
Therapeutic SC / IM injection | For palivizumab (Synagis) and nirsevimab (Beyfortus) only. RSV monoclonals are IM, not IV. Bill 96372 once per encounter. |
96374 |
IV push of a single or initial substance / drug | Not typically used for this class — all four core IV antivirals are administered as infusions, not IV push. |
96413 / 96415 |
Chemotherapy administration, IV infusion technique | NOT appropriate. Antivirals are not cytotoxic chemotherapy. Do not bill chemo admin codes despite the boxed warnings on foscarnet / cidofovir. |
Per AMA CPT guidance: chemotherapy administration codes (96401-96425) are reserved for
cytotoxic, monoclonal-antibody-as-anti-neoplastic, and certain complex biologic agents requiring special
handling. Antivirals — even with boxed warnings — do not meet that bar. Use 96365 + 96366.
Cidofovir is the trap. The mandatory probenecid pre/post-medication regimen plus pre-hydration
commonly extends the total infusion-suite chair time to 3-4 hours. Bill 96365 for the first hour of cidofovir
infusion and 96366 for each additional hour of infusion; document the cidofovir infusion start/stop times
separately from probenecid administration times in the MAR.
Modifiers (JZ, JW, JG / TB) CMS verified May 2026
JW — discarded drug from single-dose vial
All four core IV antivirals come in single-dose vials and routinely produce vial waste because of weight-based dosing. Acyclovir is the most common JW-generating agent on this page: a 700 mg dose (10 mg/kg for a 70 kg adult) drawn from a 1,000 mg vial discards 300 mg per dose. Ganciclovir 350 mg dose from a 500 mg vial discards 150 mg per dose. Foscarnet partial-bottle waste is less common because of the large bottle sizes (6,000-12,000 mg per bottle for multi-dose / multi-patient drips). Cidofovir 5 mg/kg dose for a 70 kg patient = 350 mg from a 375 mg vial — 25 mg waste per dose typical.
Per CMS's July 2023 single-dose container policy, one of JZ (no waste) or JW (waste, with the discarded units on a separate line) must be on every claim line submitted in a separately-payable setting (HOPD, freestanding infusion, office). Both pay at ASP+6%.
JZ — no discarded drug
Use JZ when the dose lands on a vial multiple with no discard. Adult cidofovir 5 mg/kg in a 75 kg patient = 375 mg = exactly one 375 mg vial, no waste → JZ. Adult ganciclovir 5 mg/kg in a 100 kg patient = 500 mg = one 500 mg vial, no waste → JZ.
JG / TB — 340B-acquired drug
For 340B-acquired antivirals administered in a Medicare HOPD, current CMS OPPS rules require JG
(or TB for informational reporting depending on your MAC) on the drug line. The 340B payment-reduction
status for separately payable drugs has shifted over recent rulemaking cycles — verify the current OPPS
year's 340B policy with your MAC. Most large transplant centers using cidofovir or foscarnet are
340B-eligible and these modifiers apply.
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 (e.g., transplant ID consult on the same day as initiation of ganciclovir IV for new CMV viremia). Routine pre-infusion clinical assessment is bundled into 96365.
Inpatient note
JW / JZ / JG modifiers are irrelevant on inpatient claims because the drug cost is bundled into the MS-DRG payment — the J-codes are not on the Part B claim. Modifier rules apply only to separately-payable outpatient and home-infusion settings.
ICD-10-CM by indication FY2026 verified May 2026
Indication codes pair with T86.x transplant complication codes for nearly all CMV billing. HSV / VZV codes drive acyclovir billing.
| Code | Description | Used for |
|---|---|---|
| HSV (drives acyclovir billing) | ||
B00.0 | Eczema herpeticum | Disseminated cutaneous HSV in atopic patients |
B00.3 | Herpesviral meningitis | Mild form; IV acyclovir indicated |
B00.4 | Herpesviral encephalitis | Primary indication for IV acyclovir 10 mg/kg q8h. HSV PCR (CSF) must be in chart |
B00.7 | Disseminated herpesviral disease | Visceral / systemic HSV in immunocompromised |
B00.81 | Herpesviral hepatitis | HSV hepatitis (transplant / pregnancy) |
B00.89 | Other herpesviral infection | Use when more specific code unavailable |
P35.2 | Congenital herpesviral (HSV) infection | Neonatal HSV (disseminated, CNS, SEM) |
| VZV / zoster (drives acyclovir billing for severe disease) | ||
B01.0 | Varicella meningitis | IV acyclovir indicated |
B01.11 | Varicella encephalitis / myelitis | IV acyclovir indicated |
B01.81 | Varicella pneumonia | Severe varicella in adult / immunocompromised |
B01.9 | Varicella without complication | Outpatient IV not usually justified — use only with documented severe disease |
B02.0 | Zoster encephalitis | IV acyclovir indicated |
B02.1 | Zoster meningitis | IV acyclovir indicated |
B02.21 | Postherpetic geniculate ganglionitis | Severe HZ with CN involvement |
B02.30 | Zoster ocular disease, unspecified | HZ ophthalmicus with vision threat → IV |
B02.7 | Disseminated zoster | Immunocompromised disseminated VZV → IV |
B02.8 | Zoster with other complications | Visceral involvement |
| CMV (drives ganciclovir / foscarnet / cidofovir / letermovir / maribavir billing) | ||
B25.0 | Cytomegaloviral pneumonitis | CMV pneumonia (transplant) |
B25.1 | Cytomegaloviral hepatitis | CMV hepatitis (transplant) |
B25.2 | Cytomegaloviral pancreatitis | CMV pancreatitis (uncommon) |
B25.8 | Other CMV diseases | CMV colitis, esophagitis, retinitis |
B25.9 | CMV disease, unspecified | CMV viremia without organ-specific disease |
B97.89 | Other viral agents as cause | Use as secondary for BK virus etc. |
| Transplant status & complication (REQUIRED secondary for nearly all CMV billing) | ||
T86.00 - T86.09 | Complications of bone marrow / HSCT | CMV in HSCT recipient |
T86.10 - T86.19 | Complications of kidney transplant | CMV / BK in kidney transplant |
T86.20 - T86.298 | Complications of heart transplant | CMV in heart transplant |
T86.30 - T86.39 | Complications of heart-lung transplant | |
T86.40 - T86.49 | Complications of liver transplant | CMV in liver transplant |
T86.5 | Complications of stem cell transplant | CMV in HSCT |
T86.810 - T86.819 | Complications of lung transplant | CMV pneumonitis in lung transplant common |
T86.90 - T86.99 | Complications of unspecified transplant | Fallback only |
Z94.0 - Z94.9 | Transplanted organ & tissue status | Always pair with T86.x to document post-transplant state |
| RSV (drives Synagis / Beyfortus billing) | ||
J21.0 | Acute bronchiolitis due to RSV | Treatment context, not prophylaxis |
Z29.11 | Encounter for prophylactic immunotherapy for RSV | Primary code for Synagis / Beyfortus prophylaxis |
P07.x | Disorders related to short gestation / low birth weight | High-risk infant qualifier for Synagis |
P27.1 | Bronchopulmonary dysplasia originating in perinatal period | BPD high-risk qualifier for Synagis |
Q20 - Q28 | Congenital malformations of cardiovascular system | Hemodynamically significant CHD qualifier for Synagis |
T86.x is the most-missed code on CMV claims. For nearly every CMV billing scenario the
payer expects both a B25.x CMV code AND a T86.x transplant-complication code to establish medical necessity
in the transplant context. Missing T86.x is a top-five denial reason for ganciclovir, foscarnet, cidofovir,
letermovir, and maribavir.
Site of care & place of service CMS OPPS & IPPS verified May 2026
Most IV antivirals are induced inpatient (DRG-bundled) and consolidated outpatient (separately payable). Home infusion supports prolonged prophylaxis and maintenance.
| Setting | POS | Form | Typical use & payment |
|---|---|---|---|
| Inpatient hospital (acute care) | 21 | UB-04 / 837I | DRG-bundled. Common: HSCT induction CMV (ganciclovir, foscarnet), HSV encephalitis (acyclovir), severe disseminated VZV. J-codes not separately payable to hospital. |
| Hospital outpatient (on-campus) | 22 | UB-04 / 837I | Separately payable at OPPS ASP+6%. Common: CMV consolidation post-HSCT discharge, cidofovir for CMV retinitis. 340B rules apply. |
| Hospital outpatient (off-campus PBD) | 19 | UB-04 / 837I | Separately payable; subject to site-neutral rules per current OPPS year. |
| Physician office / infusion clinic | 11 | CMS-1500 / 837P | Separately payable. Common: ID-clinic-managed outpatient acyclovir, ganciclovir. |
| Freestanding specialty infusion center | 11 (or 49) | CMS-1500 / 837P | Separately payable. Preferred outpatient site for prolonged courses. |
| Ambulatory infusion suite (AIC) | 49 | CMS-1500 / 837P | Separately payable. Cost-effective alternative to HOPD for stable patients. |
| Patient home (home infusion) | 12 | CMS-1500 / 837P | Common for prolonged prophylaxis / maintenance. Examples: letermovir HSCT prophylaxis through day 100/200; maintenance ganciclovir for CMV viremia control; weekly cidofovir for CMV retinitis. Requires qualified home infusion provider, nursing, and Part B home infusion benefit (HIT services S9494, S9497 etc.) or Medicare Part B home infusion therapy services. |
| Skilled nursing facility (consolidated billing) | 31 / 32 | UB-04 / 837I | Typically bundled into SNF Part A consolidated billing during a covered Part A stay; separately payable to SNF for non-covered residents under specific carve-out rules — verify CMS SNF CB exclusion list. |
| Pediatric clinic (Synagis / Beyfortus) | 11 / 22 | CMS-1500 / UB-04 | Separately payable IM administration. CPT 96372. Synagis monthly Nov-Mar season; Beyfortus single dose at season entry. |
Induction-to-consolidation pattern
A typical transplant CMV course illustrates the site-of-care economics. Patient is admitted with CMV viremia and clinical symptoms → ganciclovir IV induction 5 mg/kg q12h during inpatient stay (DRG-bundled) → discharged on continued IV ganciclovir or stepped to oral valganciclovir for maintenance → outpatient HOPD or home-infusion claims for the IV maintenance dose (separately payable J1570) until two consecutive negative PCRs. This split is why the same encounter sequence will produce very different drug-line revenue depending on where the patient sits when the dose is delivered.
Commercial inpatient pharmacy carve-outs: Some commercial and Medicare Advantage plans
handle inpatient specialty drugs through pharmacy carve-out arrangements rather than pure DRG bundling.
Verify per payer contract before assuming bundling applies.
Claim form field mapping CMS claim form guidance verified May 2026
CMS-1500 (837P) fields for outpatient separately-payable claims. UB-04 (837I) for inpatient and HOPD facility claims.
Outpatient (separately payable) — CMS-1500 / 837P
| Information | CMS-1500 box | Notes |
|---|---|---|
| NPI | 17b | Rendering provider |
| NDC qualifier + 11-digit NDC + UoM + qty | 24A shaded area | N4 + 11-digit NDC + UN (vial) or ML (solution) + qty |
| HCPCS drug code (administered line) | 24D | J0133 (acyclovir), J1570 (ganciclovir), J1455 (foscarnet), J0740 (cidofovir); use J3490 + invoice for letermovir IV |
| HCPCS drug code + JW (waste line, if applicable) | 24D (waste line) | Wasted units only; common for acyclovir / ganciclovir / cidofovir weight-based dosing |
| Drug units | 24G | Acyclovir: mg administered / 5; Ganciclovir: mg / 500; Foscarnet: mg / 1,000; Cidofovir: mg / 375 |
| CPT 96365 (admin line) | 24D (admin line) | Therapeutic IV infusion, up to 1 hr |
| CPT 96366 (admin extension) | 24D | Each additional hour beyond first (foscarnet, cidofovir + probenecid) |
| CPT 96372 (Synagis / Beyfortus admin) | 24D | Therapeutic SC/IM injection |
| ICD-10 primary | 21A | B25.x CMV / B00.4 HSV encephalitis / B02.x VZV / Z29.11 RSV prophylaxis |
| ICD-10 secondary | 21B-L | T86.x transplant complication; Z94.x transplant status; high-risk infant codes (P07.x, P27.1, Q20-Q28) for Synagis |
| PA number | 23 | Required by most plans for foscarnet, cidofovir, letermovir, Beyfortus, and step-therapy-restricted scenarios |
Inpatient — UB-04 / 837I
| Information | UB-04 form locator | Notes |
|---|---|---|
| Principal diagnosis | FL 67 | B25.x CMV / B00.4 HSV encephalitis / B02.7 disseminated VZV |
| Other diagnoses | FL 67A-Q | T86.x transplant complication, Z94.x transplant status, underlying hematologic malignancy / ESRD etc. |
| Revenue code 0250 (pharmacy general) | FL 42 | Antiviral drug cost rolls up into pharmacy charges |
| HCPCS drug code | FL 44 | Reported for cost-reporting and CCR purposes; not separately reimbursed in DRG-bundled inpatient claim |
| MS-DRG | Driven by Dx + procedure codes | Typical: MS-DRG 014-017 (post-transplant), 094-096 (bacterial / viral infection of CNS) when HSV encephalitis principal, 974-976 (HIV with major HIV-related condition) for CMV retinitis admission |
Phase 3
Get paid
CMV viremia PCR documentation, transplant ICD-10 coding, step therapy for newer agents, and renal monitoring drive most outcomes.
Payer policy snapshot Reviewed May 2026
Older agents (acyclovir, ganciclovir, foscarnet, cidofovir) generally do NOT require PA. Newer agents (letermovir, maribavir, Beyfortus) DO require PA + step therapy. Documentation focus differs by agent.
| Agent / Payer | PA? | Step therapy / requirements | Notes |
|---|---|---|---|
| Acyclovir J0133 All payers |
Generally no | HSV / VZV documented with diagnostic confirmation (PCR or clinical); IV indication justification (encephalitis, immunocompromised, disseminated) | Generic; low cost; routine coverage. Denial risk: billing IV for routine outpatient shingles in immunocompetent adult. |
| Ganciclovir J1570 All payers |
Generally no | CMV viremia PCR documented; transplant status; renal labs | Generic; transplant-driven utilization. Denial risk: missing T86.x or missing CMV PCR threshold documentation. |
| Foscarnet J1455 All payers |
Plan-specific | Documented ganciclovir failure, resistance, or contraindication; CrCl monitoring; electrolyte monitoring | Used as salvage. Many plans require documented ganciclovir failure or resistance testing. Renal monitoring is part of medical necessity. |
| Cidofovir J0740 All payers |
Yes typically | Documented step from ganciclovir + foscarnet; mandatory probenecid + hydration documented; CrCl ≥ 55; baseline UA without proteinuria | On-label use is CMV retinitis (HIV). Off-label BK virus and adenovirus salvage in HSCT routes through medical-necessity review every claim. |
| Letermovir / Prevymis All payers |
Yes | Allogeneic HSCT recipient status; CMV-seropositive recipient; baseline CMV PCR; documented HSCT date for day 100 / day 200 duration justification | IV bills J3490 with NDC + invoice (no permanent J-code 2026); oral via pharmacy benefit. High cost; step therapy documentation drives most denials. |
| Maribavir / Livtencity All payers |
Yes | Refractory CMV after documented failure of ≥ 2 standard agents (ganciclovir / valganciclovir / foscarnet / cidofovir); transplant status | Oral only — runs through Part D / pharmacy benefit, not medical J-code. Takeda Patient Assistance available. |
| Palivizumab / Synagis 90378 All payers |
Yes | AAP 2014 high-risk infant criteria (premature with chronic lung disease, hemodynamically significant CHD, certain immunocompromised); seasonal Nov-Mar | Many plans now prefer Beyfortus first-line; Synagis restricted to specific high-risk categories. |
| Nirsevimab / Beyfortus 90380 / 90381 All payers |
Yes (some plans skip) | Single dose at RSV-season entry for all infants < 8 months; high-risk infants entering 2nd season eligible 200 mg dose | Now CDC / AAP / ACIP-recommended; covered under Vaccines for Children program for eligible infants. Commercial coverage often via VFC pathway or standard immunization benefit. |
CMV viremia PCR threshold — the documentation that drives approval
Quantitative CMV PCR (reported in IU/mL per the WHO international standard) is the biomarker that drives both treatment initiation and treatment monitoring. Institution-specific thresholds vary, but typical practice in 2026 is: HSCT pre-emptive treatment initiation at ≥ 150-1,000 IU/mL depending on center; solid organ transplant pre-emptive at ≥ 1,000-10,000 IU/mL depending on transplant type and immunosuppression; CMV disease (organ-specific syndrome with confirmed viremia) treatment regardless of threshold. Document the specific PCR result and the institutional protocol threshold in the chart and in the PA submission — payers ask for both.
Guideline support
Primary references: IDSA guidelines (HSV encephalitis, neonatal HSV, VZV management); American Society of Transplantation Infectious Diseases Community of Practice (AST IDCOP) guidelines for CMV in solid organ transplant; ASTCT / ASBMT / EBMT guidelines for CMV in HSCT; AAP / CDC for RSV prophylaxis. Cite the specific recommendation grade in PA submissions and medical necessity letters.
Medicare reimbursement CMS Q2 2026 (live)
Quarterly ASP from CMS Part B Drug Pricing File. Refreshes automatically each quarter. Applies to separately-payable settings only; inpatient is DRG-bundled.
Q2 2026 payment snapshot — per drug (outpatient)
Effective April 1 – June 30, 2026 · Based on 4Q25 ASP submissions
Acyclovir J0133
$0.017
per 5 mg unit
Ganciclovir J1570
$34.047
per 500 mg unit
Foscarnet J1455
$8.356
per 1,000 mg unit
Cidofovir J0740
$560.789
per 375 mg unit
Letermovir IV
J3490
unclassified + invoice
Synagis / Beyfortus
90378 / 90380
vaccine-style code; verify MAC
Foscarnet ASP volatility 2026: Foscarnet ASP+6% rose from $6.71 per 1,000 mg in Q1 2026 to
$8.356 per 1,000 mg in Q2 2026 (a ~25% quarter-over-quarter increase) reflecting ongoing
manufacturer-shortage dynamics. Track each quarterly file release because shortage-driven ASP movement
materially changes patient OOP estimates and 340B-spread economics. The same volatility applies to cidofovir.
Sequestration: Approximately 2% reduction applies to actual paid amount in
separately-payable settings, bringing effective reimbursement to roughly ASP + 4.3% rather than ASP + 6%.
Coverage
No drug-specific NCDs for the legacy four (J0133 / J1570 / J1455 / J0740). Coverage falls under MAC LCDs and the general Part B drug coverage framework for FDA-approved on-label indications and well-supported off-label compendium uses (cidofovir for BK virus is the most commonly off-label-coded line on this page; document guideline support carefully). Letermovir IV is reviewed on a J3490 + invoice basis per MAC. Palivizumab and nirsevimab fall under preventive immunization benefits and may be paid through MMP / VFC channels for Medicaid-eligible infants.
Per-dose Medicare math (illustrative, Q2 2026 ASP+6%)
- Acyclovir 700 mg dose (10 mg/kg, 70 kg) → 140 units × $0.017 = $2.38 per dose
- Ganciclovir 350 mg dose (5 mg/kg, 70 kg) → 1 unit (rounded up from 0.7) × $34.047 = $34.05 per dose
- Foscarnet 5,400 mg dose (60 mg/kg q8h, 90 kg) → 6 units (rounded up from 5.4) × $8.356 = $50.14 per dose
- Cidofovir 375 mg dose (5 mg/kg, 75 kg) → 1 unit × $560.789 = $560.79 per dose
Patient assistance Manufacturer programs verified May 2026
- Gilead Advancing Access (Vistide / cidofovir J0740): 1-800-226-2056 / gileadadvancingaccess.com — benefits investigation, prior authorization assistance, appeal support, copay program for commercial, patient assistance program for uninsured / underinsured (typically ≤ 500% FPL).
- Merck Access Program (Prevymis / letermovir): 1-800-727-5400 / merckaccessprogram-prevymis.com — benefits investigation, prior authorization support, copay assistance for commercial (up to program max), Merck Patient Assistance Program for uninsured / underinsured.
- Takeda Patient Support (Livtencity / maribavir): 1-844-817-6468 / livtencity.com/patient-support — benefits investigation, prior authorization assistance, Takeda Help at Hand patient assistance program for eligible uninsured / underinsured patients.
- Sobi Synagis Connect (palivizumab / Synagis): 1-877-727-9637 — insurance verification, prior authorization, copay support for eligible commercial; Sobi PAP for uninsured.
- Sanofi Beyfortus Connect (nirsevimab / Beyfortus): 1-855-239-3678 / beyfortuscoverage.com — benefits investigation, VFC support, billing support for healthcare providers; commercial-only patient assistance for limited financial-hardship cases.
- Generic acyclovir / ganciclovir / foscarnet: No manufacturer programs (multi-source generics). Use foundation backup for high OOP exposure cases.
- Foundations (Medicare patients with CMV, HSV, transplant infection): PAN Foundation, HealthWell Foundation, Patient Advocate Foundation (PAF), and the National Organization for Rare Disorders (NORD) periodically open transplant infection and rare disease funds — verify current open funds quarterly at panfoundation.org, healthwellfoundation.org, patientadvocate.org.
- Inpatient note: Inpatient Medicare antiviral cost is DRG-bundled — no separate patient cost-share for the drug itself beyond standard inpatient cost-sharing.
Need to model what a specific patient will actually pay after copay assistance, deductible, coinsurance,
and OOP max? Run a CareCost Estimate — preload acyclovir, ganciclovir,
foscarnet, or cidofovir.
Phase 4
Fix problems
Missing CMV PCR documentation, missing T86.x transplant complication coding, and skipped step-therapy for newer agents are the top three.
Common denials & how to fix them
| Denial reason | Common cause | Fix |
|---|---|---|
| #1 — No CMV viremia PCR documentation | CMV J-code billed (ganciclovir / foscarnet / cidofovir / letermovir) without quantitative CMV PCR result or institutional threshold cited in chart | Submit lab report with quantitative CMV PCR (IU/mL per WHO standard) and institutional protocol threshold. Include date of result within 7-14 days of treatment initiation. Add B25.x CMV diagnosis to claim. |
| #2 — No transplant indication coding (T86.x) | CMV claim submitted with only B25.x CMV but no T86.x transplant-complication code or Z94.x transplant status | Add T86.0x (HSCT), T86.1x (kidney), T86.2x (heart), T86.4x (liver), or T86.81x (lung) per actual transplant type. Pair with Z94.x for transplant status. This is the most-missed code on CMV billing. |
| #3 — Step therapy not satisfied (newer agents) | Letermovir or maribavir submitted without documented prior-agent failure or contraindication | Letermovir: document allogeneic HSCT status + CMV-seropositive recipient + prophylaxis intent (not treatment). Maribavir: document ≥ 2 prior agents failed (genotypic resistance, clinical failure, or intolerance). Cite specific lab results, dates, and CMV PCR trend. |
| #4 — Nephrotoxicity monitoring not documented | Foscarnet or cidofovir claim without baseline + serial CrCl, electrolytes, urinalysis | Submit lab flow sheet showing baseline + 2-3x weekly creatinine on foscarnet, baseline + at every cidofovir dose. Document pre-hydration (500-1,000 mL NS for foscarnet; 1 L NS for cidofovir) and electrolyte repletion. |
| #5 — Wrong J-code for similar antiviral | Ganciclovir billed as J0133, or acyclovir billed as J1570, or foscarnet billed as cidofovir code | Match the pharmacy-dispensed drug to its specific code: J0133 = acyclovir 5 mg/unit, J1570 = ganciclovir 500 mg/unit, J1455 = foscarnet 1,000 mg/unit, J0740 = cidofovir 375 mg/unit. Each is multi-source generic but the codes are NOT interchangeable. |
| #6 — Wrong admin code (96413 for foscarnet) | Chemotherapy admin code billed because foscarnet has a boxed warning and "feels chemo-like" | Resubmit with 96365 (and 96366 for additional hours). Antivirals are non-chemo regardless of toxicity profile per AMA CPT guidance. |
| #7 — Outpatient IV billed for routine immunocompetent shingles | Acyclovir IV billed with B02.9 (zoster without complication) in an immunocompetent adult | Outpatient IV for routine adult shingles is generally not justified — oral valacyclovir / famciclovir is standard. Submit only with documented complication code (B02.0, B02.1, B02.21, B02.30, B02.7, B02.8) or documented immunocompromised state. |
| #8 — Missing JW or JZ modifier (single-dose container) | Acyclovir, ganciclovir, or cidofovir claim missing JZ (no waste) or JW (with waste) per CMS July 2023 policy | Add appropriate modifier. Common JW scenarios: 700 mg acyclovir from 1,000 mg vial (300 mg waste), 350 mg ganciclovir from 500 mg vial (150 mg waste), 350 mg cidofovir from 375 mg vial (25 mg waste). |
| #9 — Wrong NDC format | 10-digit NDC submitted instead of 11-digit with N4 qualifier | Use 11-digit NDC with N4 qualifier in 24A shaded area. Multiple generic manufacturers exist for acyclovir / ganciclovir / foscarnet — the NDC must match the specific manufacturer in pharmacy stock. |
| #10 — BK virus billed without payer pre-discussion (cidofovir off-label) | Low-dose cidofovir for BK virus nephropathy / hemorrhagic cystitis in HSCT or kidney transplant submitted as routine | This is off-label use. Submit prior authorization with KDIGO / AST guidance citation, documented BK viremia / viruria load, documented immunosuppression reduction attempt, and transplant T86.x coding. Most plans will review case-by-case. |
| #11 — Synagis billed as 96365 instead of 96372 | Palivizumab billed with IV infusion admin code instead of IM injection admin code | Resubmit with CPT 96372 (therapeutic SC/IM injection). Synagis and Beyfortus are IM injections, not IV infusions. |
| #12 — Synagis billed outside RSV season | April-September dose submitted without specific medical justification | Standard RSV season is November-March. Out-of-season doses require explicit clinical justification (e.g., late-season high-risk infant, regional RSV surveillance data showing extended season). |
| #13 — Maribavir billed as a J-code line item | Oral maribavir (Livtencity) submitted on medical claim under fabricated J-code | Maribavir is oral pharmacy benefit (Part D / commercial PBM). Refer the patient to the specialty pharmacy network. There is no IV maribavir. |
| #14 — Letermovir IV billed under wrong J-code | IV letermovir submitted with a non-existent permanent J-code | IV letermovir uses J3490 (unclassified drug) with NDC, manufacturer invoice, and full PA package for review at the MAC level. Oral letermovir runs through pharmacy benefit. |
Frequently asked questions
Which J-code do I use for CMV in a transplant patient?
For first-line CMV viremia or disease in a solid organ or HSCT transplant recipient, IV ganciclovir is the
standard induction agent and bills under J1570 (ganciclovir sodium, 500 mg per unit). For
ganciclovir-resistant or refractory CMV, foscarnet (J1455, 1,000 mg per unit) or cidofovir
(J0740, 375 mg per unit) are used. The newer agent maribavir (Livtencity) for refractory
post-transplant CMV is currently oral-only and does not have a J-code billing pathway. Letermovir (Prevymis)
is used for HSCT prophylaxis (not treatment); IV letermovir bills under J3490 unclassified with
NDC and invoice. The T86.x transplant-complication ICD-10 series must accompany the B25.x CMV codes
to support medical necessity.
Livtencity vs Prevymis vs ganciclovir / valganciclovir — which is for what?
These are NOT interchangeable. IV ganciclovir (J1570) and oral valganciclovir (Valcyte, pharmacy benefit) are the first-line standard for CMV viremia and disease treatment. Letermovir / Prevymis (Merck) is approved for CMV prophylaxis in allogeneic HSCT recipients and adult kidney transplant — it prevents CMV reactivation; it is NOT a treatment agent for established disease. Maribavir / Livtencity (Takeda) is approved for refractory post-transplant CMV after failure of ganciclovir, valganciclovir, foscarnet, or cidofovir, but it is oral only — there is no IV maribavir. Step-therapy documentation for both Prevymis and Livtencity drives most denials for these newer high-cost agents.
How is foscarnet nephrotoxicity monitored?
Foscarnet (J1455) carries an FDA boxed warning for renal impairment and electrolyte disturbances. Standard monitoring is serum creatinine at least 2-3 times weekly during induction and at least once weekly during maintenance, plus electrolytes (calcium, magnesium, phosphate, potassium) at the same cadence because foscarnet chelates divalent cations. Dose adjustments based on creatinine clearance are mandatory and must be documented in the chart for both clinical safety and payer-policy compliance. Aggressive pre-hydration (500-1,000 mL normal saline) before each dose reduces nephrotoxicity and supports medical necessity for the additional admin time billed under CPT 96365 / 96366.
What is the IV acyclovir dose for HSV encephalitis?
10 mg/kg IV every 8 hours for 14 to 21 days per IDSA guidelines, infused over at least 1
hour to avoid nephrotoxicity from crystallization in renal tubules. For a 70 kg adult, that calculates to
700 mg per dose, three times daily, for a typical 14-day course total of 29,400 mg (5,880 units of
J0133 at 5 mg per unit). HSV PCR (CSF) must be documented for medical necessity.
How is BK virus treated and billed since there is no FDA-approved antiviral?
BK virus nephropathy and hemorrhagic cystitis in kidney transplant and HSCT recipients have no
FDA-approved antiviral. The mainstay of management is reduction of immunosuppression. Off-label
cidofovir (J0740) at very low doses (commonly 0.25-1 mg/kg IV every 1-2 weeks, with or without
probenecid) is the most-used pharmacologic salvage; intravesical cidofovir is also used. Because BK is
off-label, the J0740 line routes through medical-necessity review at most payers. Document the specific
transplant type, the BK viremia / viruria load, the immunosuppression reduction attempted first, and society
guideline citation (KDIGO / AST) in the PA submission.
How does pediatric IV antiviral dosing differ from adult?
Pediatric IV antiviral dosing is weight-based across all four core agents and is generally higher per kg than adult dosing for HSV. Acyclovir: neonatal HSV 20 mg/kg IV q8h for 14-21 days; pediatric encephalitis 20 mg/kg q8h in infants, 15 mg/kg q8h in older children; pediatric VZV/HSV otherwise 10 mg/kg q8h. Ganciclovir, foscarnet, and cidofovir use adult mg/kg dosing in older children with the same renal adjustments. JW vial-waste billing is more common in pediatric encounters because of fractional vial use; document the discarded mg on a separate JW-modified line.
Why is the outpatient drug cost so much higher than inpatient for the same antiviral?
Two effects. First, for Medicare inpatient stays the drug cost is packaged into the MS-DRG payment — the hospital is reimbursed a fixed amount and the antiviral is not separately payable. Outpatient (HOPD, freestanding infusion, home infusion) bills the J-code separately at ASP+6%. Second, the per-mg ASP for several of these legacy generics has spiked because of the foscarnet and cidofovir manufacturer-shortage environment — foscarnet ASP rose from $6.71/1,000 mg in Q1 2026 to $8.356/1,000 mg in Q2 2026, and cidofovir ASP runs at $560.789/375 mg. Track these quarterly.
Synagis (90378) vs Beyfortus (90380) for RSV prophylaxis — which is billed when?
Both are RSV prophylactic monoclonals given by intramuscular (IM) injection — not IV infusion.
Palivizumab (Synagis, Sobi) bills under 90378 (50 mg per unit) and has been the standard since
1998 for high-risk infants during RSV season; dose 15 mg/kg IM monthly up to 5 doses per season.
Nirsevimab (Beyfortus, Sanofi / AstraZeneca) bills under 90380 (50 mg per unit) and was
approved in 2023 as a single-dose seasonal prophylactic for all infants entering their first RSV season
— which has substantially shifted volume away from Synagis since 2023-2024. Many commercial payers and
state Medicaid now prefer Beyfortus first-line. Both use CPT 96372 for administration —
NOT 96365 IV infusion codes.
When does VZV require IV antiviral rather than oral?
IV acyclovir 10 mg/kg q8h is reserved for: (1) immunocompromised patients with disseminated zoster, visceral involvement, or extensive cutaneous disease (HSCT, solid organ transplant, advanced HIV, hematologic malignancy on chemotherapy); (2) VZV ophthalmicus with sight-threatening complications or any VZV with CNS involvement (meningitis, encephalitis, vasculopathy); (3) severe pediatric varicella in neonates or immunocompromised children. Routine immunocompetent adult shingles is oral therapy — billing IV J0133 for routine outpatient shingles will trigger denial.
How long is letermovir / Prevymis prophylaxis given after HSCT?
Per FDA label and IDSA / ASTCT guidelines, letermovir is initiated through day 28 post-HSCT and continued through day 100 post-HSCT in the original adult indication. In 2023 the FDA expanded the label to extend prophylaxis through day 200 post-HSCT for high-risk CMV-seropositive HSCT recipients with ongoing risk of reactivation (steroid-treated GVHD, T-cell-depleted graft, certain haploidentical transplants). Document HSCT status, the underlying hematologic malignancy, and the high-risk justification to support the extended 200-day course. IV and oral letermovir are interchangeable per label — most patients step to oral once tolerating PO.
Reference
Sources & methodology
Every claim on this page is sourced. Methodology and review history below.
Source documents
- DailyMed — Acyclovir Sodium Injection (multi-source generic)
- DailyMed — Ganciclovir Sodium for Injection
- DailyMed — Foscarnet Sodium Injection
- FDA — Vistide (cidofovir) prescribing information (NDA 020638)
- FDA — Prevymis (letermovir) prescribing information (NDA 209940)
- FDA — Livtencity (maribavir) prescribing information (NDA 215596)
- FDA — Synagis (palivizumab) prescribing information (BLA 103770)
- FDA — Beyfortus (nirsevimab-alip) prescribing information (BLA 761328)
- CMS — Medicare Part B Drug ASP Pricing File
- IDSA Guidelines — Management of Encephalitis
- AST IDCOP Guidelines — Cytomegalovirus in Solid Organ Transplantation (3rd Edition)
- ASTCT Guidelines — CMV in Hematopoietic Cell Transplantation
- AAP Red Book — RSV Prophylaxis Recommendations
- CDC ACIP — Recommendations for RSV Prevention
- CMS — Hospital Outpatient Prospective Payment System (OPPS)
- CMS HCPCS Level II Quarterly Updates
- FDA National Drug Code Directory
- CMS — JW / JZ modifier policy (CR 12056, eff. July 2023)
About this page
We maintain this page as a living class reference. Medicare ASP pricing is bound to our underlying CareCost data layer and refreshes automatically when CMS publishes new quarterly files. Coding and policy content is reviewed at least quarterly 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 | Quarterly | Auto-bound to CareCost ASP layer; updates on CMS file release. |
| Payer policies (UHC, Aetna, Cigna, BCBS, Medicare MACs) | 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 manufacturer document version + FDA label revision date. |
| Transplant ID guidelines (IDSA, AST, ASTCT) | Annual | Reviewed against current society guideline editions. |
Reviewer
Pending SME review. This page is staff-authored from primary sources (FDA, CMS, IDSA, AST,
ASTCT, AAP, manufacturer prescribing information — all linked above). Editorial review in progress.
Until that review is complete, treat this as a draft reference and verify each cited source for high-stakes
claims.
Change log
- — Initial publication. ASP data: Q2 2026. Covers acyclovir (J0133), ganciclovir (J1570), foscarnet (J1455), cidofovir (J0740), letermovir (J3490 unclassified), maribavir (oral, no J-code), palivizumab (90378), nirsevimab (90380 / 90381). Excludes Veklury (remdesivir J0248 — see dedicated page).
Methodology
Every claim on this page is sourced inline. Pricing reflects the current CMS Part B Drug ASP Pricing File. Payer policies are read directly from each payer's published medical / pharmacy policy documents. Indication list and dosing are verified against the current FDA labels and society guideline editions for transplant infectious disease. We do not paraphrase from billing-software vendor blogs.