Reimbursement
$0.00
Threshold
N/A
2026 Status
Active
What is CPT Code J3490?
CPT J3490 is defined as: A HCPCS Level II code used to report drugs that do not have a specific, dedicated HCPCS code. This includes new drugs recently approved by the FDA that have not yet been assigned a permanent code, or older drugs that are used infrequently and lack a specific identifier. It is a 'catch-all' code that requires manual review by the payer for pricing and clinical appropriateness.
This code is primarily used for Labs services. It falls under the category of Drugs (J-Codes) and is valid for the 2026 calendar year according to the CMS Physician Fee Schedule.
2026 RVU Components
Relative Value Units (Non-Facility)
Work RVU
0
Physician Effort
PE (Non-Fac)
0
Practice Expense
Malpractice
0
Risk Factor
Total RVU
0
Note: Contractor Priced. Payment typically = 95% of AWP or Invoice Cost.
2026 CMS Policy Intelligence
contractor pricing
J3490 remains a manual-review code in 2026. MACs (Medicare Administrative Contractors) have updated their 'Unlisted/Unclassified' pricing tables to reflect current market rates.
audit scrutiny
Because it requires manual review, J3490 claims have a significantly higher rate of initial denial or 'Request for Information' (RFI) than classified codes.
conversion factor
The $33.40 conversion factor is not used for pricing J3490; it is drug-reimbursement based.
Administrative Framework
Place of Service
NCCI Exclusions
Key Modifiers
Operational Requirements
mandatory claim info
Claims for J3490 must include the Drug Name, NDC (National Drug Code), Dosage administered, and the clinical reason for using an unclassified agent in the 'Box 19' (or electronic equivalent) of the claim form.
invoice requirement
For high-cost or very new drugs, payers may require the submission of the acquisition invoice to determine reimbursement.
manual pricing
This code is 'Contractor Priced' (or MAC priced), meaning there is no fixed national fee. Payment is determined locally based on Average Sales Price (ASP) plus 6%, or a percentage of the Average Wholesale Price (AWP).
jz modifier mandate
As of 2026, the JZ modifier must be appended if no drug was wasted, or the claim will be denied.
Compliance Checklist
Audit Defense
No specific audit defense elements defined.
2026 Update
Contractor priced. JZ/JW modifiers are mandatory for 2026. Claim must include descriptive drug info in Box 19.
Common Clinical Scenarios
No clinical examples provided.
Target Specialties & Utilization
Typical Clinical Indications (ICD-10)
Frequently Asked Questions
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