HCPCS Code J0739: Injection of Cabotegravir, Specifically 1mg, for HIV Pre Exposure Prophylaxis (PrEP)

Learn about HCPCS J0739 for cabotegravir injections, including coverage and coding rules, for accurate HIV prevention claims.

Use Code

## **What is an injection of cabotegravir?** HCPCS code J0739 is defined as per 1 mg of cabotegravir administered via injection. An injection of cabotegravir 1mg is an FDA-approved prescription drug used for HIV pre-exposure prophylaxis (PrEP) in at-risk individuals. It is administered as an injection (typically intramuscular), providing an alternative to daily oral PrEP. Actual clinical doses are usually higher (e.g., 600 mg every 8 weeks after initial loading doses). It helps prevent human immunodeficiency virus (HIV) in individuals at risk by blocking the virus from establishing infection in the body. Unlike daily oral PrEP drugs, cabotegravir is a physician-administered injection, making it easier for some patients to maintain medication adherence. Healthcare providers use cabotegravir alongside HIV risk assessment, individual counseling, and continued assessment to support HIV prevention and HIV risk reduction strategies. It is intended for initial or continued assessments to support HIV prevention and risk reduction strategies. It is intended for initial or continued use as HIV PrEP, but it is prescription-only for use under a qualified health professional.

## **Documentation requirements** When submitting claims for HCPCS code J0739 (injection, cabotegravir 1mg), providers must ensure their documentation supports medical necessity and compliance with CMS and Medicare billing guidelines. Because cabotegravir is an FDA-approved prescription drug used for HIV pre-exposure prophylaxis (PrEP), claims must demonstrate that it was prescribed only for use under a qualified health professional. Key documentation should include: - A confirmed HIV risk assessment with details on the patient’s eligibility to prevent HIV and risk reduction. - Evidence of individual counseling, initial or continued assessment, and ongoing monitoring for medication adherence to prevent human immunodeficiency virus (HIV). - A treatment plan showing the use of HIV PrEP, either as an initial prescription or for continued assessment of adherence. - Confirmation that the drug was physician-administered by clinical staff rather than dispensed as oral PrEP drugs. - Documentation verifying uninterrupted access to the therapy, especially when the pharmacy supplying fee is billed with the following HCPCS codes. - Notation that prophylaxis is not for use in individuals already diagnosed with HIV. For proper reimbursement, providers should also record the drug name, strength, dosage (injection cabotegravir 1mg FDA approved), and route of administration. Supporting documentation helps ensure claims submitted meet DME MAC and Medicare requirements. This reduces denials and supports compliance when you submit claims for this prescription drug treatment.

## **Billing requirements** - Bill under part B using the drugs-as-preventive-services (DCAPS) fee schedule as per Medicare’s pre-exposure prophylaxis (PrEP) coverage policy for HIV prevention. Coverage includes cabotegravir with no deductibles or coinsurance (Centers for Medicare & Medicaid Services, 2024). - Submit using J0739 only when the injection is used for HIV pre-exposure prophylaxis (not as a treatment). Pair the submission with an appropriate diagnosis code like Z29.81 (encounter for HIV PrEP). - Include the pharmacy supplying fee, if applicable, on the same claim using codes such as Q0521 (starting January 1, 2025) to cover dispensing services for injectable PrEP. - Don’t include patient cost-sharing (deductible or coinsurance); PrEP-related drugs and counseling are exempt from cost-sharing under Medicare. - Track reimbursement expectations with typical Medicare rates around $6.89 to $7.03 per mg, though rates vary by payer and locality (Find-a-Code, n.d.). - Ensure claim alignment with setting: pharmacies billing under Part B must be enrolled appropriately (DMEPOS or Part B pharmacy supplier). Practitioners should submit buy-and-bill claims to the A/B MAC.

## **Other relevant codes** - **J0740** – Injection, cidofovir, 375 mg

## **References** Centers for Medicare & Medicaid Services. (2024). Pre-exposure prophylaxis (PrEP) for HIV prevention. https://www.cms.gov/files/document/mm13843-national-coverage-determination-21015-pre-exposure-prophylaxis-prep-hiv-prevention.pdf Find-a-Code. (n.d.). J0739 HIV PrEP injection, cabotegravir 1 mg HCPCS procedure & supply codes. https://www.findacode.com/hcpcs/j0739-injection-cabotegravir-mg-hcpcs-code.html

Frequently asked questions

Yes. Medicare covers cabotegravir when prescribed for HIV pre-exposure prophylaxis (PrEP) under its expanded coverage policy. HCPCS code J0739 is primarily indicated and covered for HIV pre-exposure prophylaxis (PrEP) in at-risk HIV-negative individuals. While cabotegravir extended-release injectable formulations are FDA-approved as part of HIV treatment regimens for people living with HIV, J0739 is generally not used or covered for treatment purposes under most payer policies. Coverage and coding for treatment with cabotegravir typically use a different HCPCS code (e.g., J0741 for cabotegravir and rilpivirine combination). Providers should verify payer-specific policies to determine appropriate code use and coverage for treatment indications.

Yes. J0739 only represents the drug. Providers must also bill the appropriate CPT injection administration code (e.g., 96372) to capture the service of administering the medication.

It is billed per 1 mg of cabotegravir. Since injections are typically given in larger doses, the total units reported should reflect the exact milligrams administered to the patient.