HCPCS code J9271: Injection, Pembrolizumab, 1 mg

## **What is HCPCS code J9271?** HCPCS code J9271 is a code that has a description: Injection, pembrolizumab, 1 mg, as maintained by CMS, falls under Chemotherapy Drugs. It represents an intravenous injection of pembrolizumab (Keytruda), a highly complex drug, billed per 1 mg of the drug. Pembrolizumab is a PD-1 immune checkpoint inhibitor widely used in oncology to help the immune system fight cancer cells and to treat various malignancies—including metastatic melanoma, non-small cell lung cancer (NSCLC), head and neck cancers, metastatic urothelial carcinoma, Hodgkin lymphoma, MSI-high/dMMR tumors, and others as indicated by FDA approvals and payer clinical policies.

## **HCPCS code J9271 documentation requirements** To ensure proper billing and medical necessity, documentation for J9271 must include: - **Diagnosis**: The specific cancer diagnosis being treated, such as non-small cell lung cancer or mesothelioma, breast cancer, neck squamous cell carcinoma, along with the correct ICD-10-CM diagnosis code. - **Medical necessity**: Clear justification for the use of pemetrexed, including the patient's condition, treatment plan, and why this particular drug is the best course of action. - **Dosage and administration**: The exact dosage administered (e.g., J9271 x 5 for 500 mg), the route of administration (e.g., intravenous infusion), and the date of service. - **Physician's order**: A signed and dated order from the prescribing physician is typically required. - **Infusion log**: A detailed log of the drug's preparation and administration, including lot numbers and expiration dates. - **Patient consent**: Documentation of informed consent from the patient regarding the treatment plan and potential side effects.

## **J9271 billing requirements** Billing for J9271 involves several key steps and considerations: - **Unit of service**: Each unit of J9271 represents 100 mg. If a patient receives 500 mg, you would bill J9271 with a quantity of 5. - **Place of service**: This specific code is typically billed for services performed in a hospital outpatient department (POS 22) or a physician's office (POS 11). - **Medically unlikely edits (MUEs)**: MUEs set a maximum number of units that a provider can bill for a single patient on a single date of service. - **Modifiers**: Modifiers may be necessary to provide additional context. For example, the JW modifier is used to indicate the amount of drug that was discarded or wasted in single-dose vials. - **National drug code (NDC)**: Some payers require the NDC of the specific drug used in the claim submission.

## **Other related codes** - **J9272**: Injection, dostarlimab-gxly, 10 mg - **J9299**: Injection, nivolumab, 1 mg

Frequently asked questions

You would bill J9271 × 200 units, as each unit equals 1 mg.

Yes. Use JW to indicate any drug wastage, and JZ when the entire vial is administered with no waste. For single-use vials like Keytruda, JZ is mandatory when no discard occurs.

Coverage depends on the payer and other guidelines, such as indication-specific policies. Examples include: MSI-high/dMMR tumors, NSCLC, melanoma, head/neck cancers, urothelial carcinoma, Hodgkin lymphoma, and others as outlined in UnitedHealthcare coverage tables. Claims must include appropriate additional codes (ICD-10) based on diagnosis.