Heads up: this issue is from February 11, 2026. Because it covers time-sensitive coding and regulatory topics, some details may have changed since. See the latest issues for current guidance.
The Transmittal for First Quarter, 2026, was delayed almost a month. What? At this point, we can say this transmittal is action-packed and important. I would guess that is why the MACs had to scramble in the first month of 2026. Anyway, check it out — some really useful content.
ASP Changes from the Final Rule
Effective January 1, 2026, payment rates for many drugs and biologicals have changed from the values published in the CY 2026 OPPS/ASC final rule due to new ASP calculations based on sales price submissions from the third quarter of CY 2025. In cases where adjustments to payment rates are necessary, they will be incorporated into the January 2026 Fiscal Intermediary Standard System (FISS) release. CMS is not publishing the updated payment rates in this Change Request; it is implementing the January 2026 OPPS update. However, the updated payment rates, effective January 1, 2026, can be found in the January 2026 update to the OPPS Addenda A and B on the CMS website.
Drug/Biologic Invoice Pricing
I have often wondered why the methods for dealing with drugs without pricing differed for offices and hospitals. It was stated briefly last year that Medicare would change this. As of January 1, the payment method is not so different. Starting for dates of service on and after January 1, 2026, CMS has implemented the use of value code "92" for providers to report invoice pricing for certain drugs/biologicals with OPPS Status Indicator (SI) "E2" where no pricing is available but other applicable requirements are met, and the claim includes one of the revenue categories "0343", "0344", "0636", or "089X."
Value Code "92” was approved by the National Uniform Billing Committee (NUBC) for use by providers when federal regulations require for separate payment, invoice pricing for drug/biological services. Drug/biological lines that contain services with an OPPS STATUS INDICATOR of "E2" and one of the revenue categories “0343”, "0344", “0636”, or “089X” may qualify for invoice pricing under Medicare. In recent years there has been an increasing number of drug and biological HCPCS codes for which Average Sale Price (ASP), Wholesale Acquisition Cost (WAC), Average Wholesale Price (AWP), and Mean Unit Cost (MUC) information is not available. As a result, Medicare cannot assign a payable status indicator to these drugs or biologicals because there is no payment data available.
For CY 2026, Medicare has updated the system to allow the use of the provider invoice amount to set a payment rate for a separately payable drug, biological, or radiopharmaceutical until its payment amount becomes available and CMS provides a payment rate in Addendum B. HCPCS code(s) with missing payment rate in Addendum B for a separately payable drug, biological, or radiopharmaceutical will indicate that CMS does not have pricing information would then calculate the payment for the product based on provider invoices, if the applicable Per-Day Cost (PDC) has been met. If all requirements are met, Reason Code W7013 will be bypassed, and the invoice payment policy will be applied. If a drug/biological line does not meet these requirements, that service line will continue to have reason code W7013 applied.
Additionally, in rare instances when more than one invoice-priced drug is reported on a claim, a provider shall indicate the total amount of all invoiced drugs in value code 92 and, in remarks, report the invoice amount for each individually invoiced priced HCPCS.
Payment for Drug Administration Services at Excepted Provider-Based Departments (PBDs)
In the CY OPPS final rule, CMS finalized a policy to apply an amount equal to the site-specific Physician Fee Schedule (PFS) payment rate for non-excepted items and services furnished by a non-excepted off-campus Provider-Based Department (PBD) (the PFS equivalent payment rate) for HCPCS codes assigned to the drug administration services APCs (5691-5694), when provided at an excepted off-campus PBD. These off-site clinics must use Modifier -PO for items and services billed to Medicare.
Radiation Changes for Off-Campus PBDs
Effective January 1, 2026, CMS is deleting existing radiation therapy G-codes (G6001 through G6017) that describe imaging guidance for radiation treatment (G6001, G6002, G6017) and radiation treatment delivery (G6003-G6015) because CPT codes 77402, 77407, and 77412 will be used to report these services instead.
Effective January 1, 2026, non-excepted off-campus PBDs will use CPT codes 77402, 77407, and 77412 with the PN modifier to continue the existing policy of paying the PFS-equivalent rate for these services to these departments.
Outpatient Outliers
For hospital outlier payments under OPPS, the 1.75 multiple threshold will remain unchanged in 2026. This threshold of 1.75 is multiplied by the total line-item APC payment to determine eligibility for outlier payments. This factor is also used to determine the outlier payment, which is 50 percent of the estimated cost, less 1.75 times the APC payment amount. The payment formula is (cost-(APC payment x 1.75))/2. The fixed-dollar threshold for OPPS outlier payments decreases in CY 2026 relative to CY 2025. The estimated cost of a service must exceed the APC payment amount plus $6,225 to qualify for outlier payments.
Drugs Receiving Pass-Through Status January 1, 2026
C9307--Injection, linvoseltamab-gcpt, 1 mg
C9308--Injection, carboplatin (avyxa), 1 mg
J1737--Injection, meloxicam (azurity), 1 mg
J9184--Injection, gemcitabine hydrochloride (avyxa), 200 mg
J9282--Mitomycin, intravesical instillation, 1 mg
Q5160--Injection, bevacizumab-nwgd (jobevne), biosimilar, 10 mg
J9275--Injection, cosibelimab-ipdl, 2 mg
Q5158--Injection, denosumab-bnht (bomyntra/conexxence), biosimilar, 1 mg
Drugs With Pass-Through Status Ending January 1, 2026
J0225--Injection, vutrisiran, 1 mg
J1932--Injection, lanreotide, (cipla), 1 mg
J2327--Injection, risankizumab-rzaa, intravenous, 1 mg
Q5124--Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg
Drugs with Status Indicator Changes Effective 1/1/2026 (A Complete List of Status Indicators is here)
CY 2026 HCPCS Code/CY 2026 Long Descriptor /January 2026 Status Ind
90385--rho(d) immune globulin (rhig), human, mini-dose. K
90476--adenovirus vaccine, type 4, live, for oral use. E1
90634--hepatitis a vaccine, pediatric/adolescent dosage-3 dose schedule. N
90680--rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use. N
90710--measles, mumps, rubella, and varicella vaccine (mmrv), live, for subcutaneous use.E1
A9507--indium in-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries. K
A9508--iodine i-131 iobenguane sulfate, diagnostic, per 0.5 millicurie. K
A9532--iodine i-125 serum albumin, diagnostic, per 5 microcuries. K
A9542--indium in-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries. N
A9551--technetium tc-99m succimer, diagnostic, per study dose, up to 10 millicuries. K
A9553--chromium cr-51 sodium chromate, diagnostic, per study dose, up to 250 microcuries. K
A9554--iodine i-125 sodium iothalamate, diagnostic, per study dose, up to 10 microcuries. K
A9568--technetium tc-99m arcitumomab, diagnostic, per study dose, up to 25 millicuries. E1
C9047--Injection, caplacizumab-yhdp, 1 mg. K
C9144--Injection, bupivacaine (posimir), 1 mg. E1
C9293--Injection, glucarpidase, 10 units. K
C9488--Injection, conivaptan hydrochloride, 1 mg. E2
J0122--Injection, eravacycline, 1 mg. K
J0139--Injection, adalimumab, 1 mg. E1
J0209--Injection, sodium thiosulfate (hope), 100 mg. K
J0220--Injection, alglucosidase alfa, 10 mg, not otherwise classified. E2
J0225--Injection, vutrisiran, 1 mg. K
J0287--injection, amphotericin b lipid complex, 10 mg. E1
J0470--Injection, dimercaprol, per 100 mg. E2
J0599--Injection, c-1 esterase inhibitor (human), (haegarda), 10 units. E1
J0606--Injection, etelcalcetide, 0.1 mg. K
J0630--Injection, calcitonin salmon, up to 400 units. E1
J0652--Injection, levothyroxine sodium (hikma), not therapeutically equivalent to J0650, 10 mcg. N
J0687-Injection, cefazolin sodium (wg critical care), not therapeutically equivalent to j0690, 500 mg. N
J0688--Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg. N
J0691--Injection, lefamulin, 1 mg. E2
J0720--Injection, chloramphenicol sodium succinate, up to 1 gm. K
J0742--Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg. N
J0801--Injection, corticotropin (acthar gel), up to 40 units. K
J0802--Injection, corticotropin (ani), up to 40 units. K
J0872-Injection, daptomycin (xellia), unrefrigerated, not therapeutically equivalent to j0878 or j0873, 1 mg. N
J0873--Injection, daptomycin (xellia), not therapeutically equivalent to j0878 or j0872, 1 mg. N
J0879--Injection, difelikefalin, 0.1 microgram, (for esrd on dialysis). N
J0888--Injection, Epoetin Beta, 1 microgram, (Non-ESRD use). N
J0892--Injection, argatroban (accord), not therapeutically equivalent to j0884, 1 mg (for esrd on dialysis). E2
J0898--Injection, argatroban (auromedics), not therapeutically equivalent to j0883, 1 mg (for nonesrd use). N
J1010--Injection, methylprednisolone acetate, 1 mg. N
J1105--Dexmedetomidine, oral, 1 mcg. E1
J1130--Injection, diclofenac sodium, 0.5 mg. E2
J1320--Injection, amitriptyline hcl, up to 20 mg. E2
J1327--Injection, eptifibatide, 5 mg. K
J1427--Injection, viltolarsen, 10 mg. E2
J1429--Injection, golodirsen, 10 mg. E2
J1438--Injection, etanercept, 25 mg, not self-administered . E1
J1455--injection, foscarnet sodium, per 1000 mg. N
J1458--Injection, galsulfase, per 5 mg. K
J1551--Injection, immune globulin (cutaquig), 100 mg. K
J1556--Injection, immune globulin (Bivigam), 500 mg. K
J1595--injection, glatiramer acetate, 20 mg. E1
J1596--Injection, glycopyrrolate, 0.1 mg. N
J1598--Injection, glycopyrrolate (fresenius kabi), not therapeutically equivalent to J1596, 0.1 mg. N
J1632--Injection, brexanolone, 1mg. E1
J1729--Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg. E2
J1744--Injection, icatibant, 1 mg. E1
J1748--Injection, infliximab-dyyb (zymfentra), 10 mg. K
J1811--Insulin (fiasp) for administration through dme (i.e., insulin pump) per 50 units. N
J1826--Injection, interferon beta-1a, 30 mcg. E1
J1932--Injection, lanreotide, (cipla), 1 mg. K
J1939--Injection, bumetanide, 0.5 mg. N
J2002--Injection, lidocaine hcl in 5% dextrose, 1 mg. N
J2170--Injection, mecasermin, 1 mg. E1
J2183--Injection, meropenem (wg critical care), not therapeutically equivalent to j2185, 100 mg. N
J2212--Injection, methylnaltrexone, 0.1 mg. E1
J2327--Injection, risankizumab-rzaa, intravenous, 1 mg. K
J2358--Injection, olanzapine, long-acting, 1mg. N
J2373--Injection, phenylephrine hydrochloride (immphentiv), 20 micrograms. N
J2440--injection, papaverine hcl, up to 60 mg. E1
J2510--Injection, penicillin g procaine, aqueous, up to 600,000 units. E2
J2515--Injection, pentobarbital sodium, per 50 mg. K
J2597--Injection, desmopressin acetate, per 1 mcg. N
J2650--Injection, prednisolone acetate, up to 1 ml. N
J2679--Injection, fluphenazine hcl, 1.25 mg. N
J2770--Iinjection, quinupristin/dalfopristin, 500 mg (150/350). N
J2793--Injection, rilonacept, 1 mg. E2
J2919--Injection, methylprednisolone sodium succinate, 5 mg. N
J2941--Injection, somatropin, 1 mg. E1
J3030--Injection, sumatriptan succinate, 6 mg. E1
J3031--Injection, fremanezumab-vfrm, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered). E1
J3350--Injection, urea, up to 40 g. N
J3357--Injection, ustekinumab, 1 mg. E1
J3425--Injection, hydroxocobalamin, intramuscular, 10 mcg. N
J3485--Injection, zidovudine, 10 mg. K
J7191--Factor VIII (antihemophilic factor (porcine)), per i.u. K
J7200--Factor ix (antihemophilic factor, recombinant), Rixubus, per i.u.. K
J7212--Factor viia (antihemophilic factor, recombinant)jncw (sevenfact), 1 microgram. K
J7316--Injection, Ocriplasmin, 0.125mg. E1
J7328--Hyaluronan or derivative, gelsyn-3, for intraarticular injection, 0.1 mg. K
J7356--Injection, foscarbidopa 0.25 mg/foslevodopa 5 mg. E1
J8560--etoposide; oral, 50 mg. K
J8705--Topotecan, oral, 0.25 mg. K
J9017--Injection, arsenic trioxide, 1 mg. N
J9030--BCG live intravesical instillation, 1 mg. K
J9051--Injection, bortezomib (maia), not therapeutically equivalent to j9041, 0.1 mg. N
J9052--Injection, carmustine (accord), not therapeutically equivalent to j9050, 100 mg. E1
J9150--Injection, daunorubicin, 10 mg, N
J9185--Injection, fludarabine phosphate, 50 mg. N
J9218--leuprolide acetate, per 1 mg. E1
J9225--Histrelin implant (vantas), 50 mg. E2
J9230--Injection, mechlorethamine hydrochloride, (nitrogen mustard), 10 mg. E2
J9255--Injection, methotrexate (accord), not therapeutically equivalent to J9260, 50 mg. N
J9275--Injection, cosibelimab-ipdl, 2 mg. G
J9285--Injection, olaratumab, 10 mg. E2
J9320--Injection, streptozocin, 1 gram. E2
J9395--Injection, fulvestrant, 25 mg. N
P9041--infusion, albumin (human), 5%, 50 ml. K
P9047--infusion, albumin (human), 25%, 50 ml. K
Q0180--dolasetron mesylate, 100 mg, oral, fda approved prescription anti-emetic, for use as a complete
E2
Q2009--Injection, Fosphenytoin, 50 mg phenytoin equivalent. K
Q3027--Injection, Interferon Beta-1a, 1 mcg For Intramuscular Use. E1
Q5098--Injection, ustekinumab-srlf (imuldosa), biosimilar, 1 mg. E1
Q5099--Injection, ustekinumab-stba (steqeyma), biosimilar, 1 mg. E1
Q5105--Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for esrd on dialysis), 100 units. N
Q5124--Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg. K
Q5134--Injection, natalizumab-sztn (tyruko), biosimilar, 1 mg. K
Q5137--Injection, ustekinumab-auub (wezlana), biosimilar, subcutaneous, 1 mg. E1
Q5140--Injection, adalimumab-fkjp, biosimilar, 1 mg. E1
Q5141--Injection, adalimumab-aaty, biosimilar, 1 mg. E1
Q5142--Injection, adalimumab-ryvk biosimilar, 1 mg. E1
Q5143--Injection, adalimumab-adbm, biosimilar, 1 mg. E1
Q5144--Injection, adalimumab-aacf (idacio), biosimilar, 1 mg. E1
Q5145--Injection, adalimumab-afzb (abrilada), biosimilar, 1 mg.
Q5158--Injection, denosumab-bnht (bomyntra/conexxence), biosimilar, 1 mg. G
Q9996--Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg. E1
Long Descriptor Change for HCPCS Effective 1/1/2026
J7322 FROM Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg TO: Hyaluronan or derivative, hymovis or hymovis one, for intra-articular injection, 1 mg
Again, to view the Transmittal, it is here.
