J1438
J1438 – Injection, etanercept, 25 mg (code may be used for medicare when drug ad · NDC Crosswalk & Billing Units
HCPCS Level II J-code · Medicare Part B drug billing
J-code
● 19 NDCs crosswalked
📋 J1438 summary
J1438 is a HCPCS Level II J-code used to bill etanercept, 25 mg (code may be used for medicare when drug administered under the direct s.... The number of billing units to report depends on the dose administered and the NDC/package billed — use the calculator below.
Brand names associated with J1438: Enbrel
⚠ An NDC↔HCPCS crosswalk and a published payment limit do not guarantee payer coverage or payment. Always verify the current payer policy and claim format before billing.
🗂️ Key billing facts
HCPCS codeJ1438
DescriptorInjection, etanercept, 25 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)
Billing unitNot available in current dataset
Payment limit / unit Not available in current dataset
Mapped NDCs19
Data periodNot available in current dataset
Last updatedSource date not available
💊 About Etanercept Injection DRUG GUIDE
Enbrel (etanercept) injection is approved to treat several inflammatory conditions.
In adults, it is used for moderately to severely active rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and chronic moderate-to-severe plaque psoriasis.In children, Enbrel is approved for polyarticular juvenile idiopathic arthritis and juvenile psoriatic arthritis in patients 2 years and older, and for chronic moderate-to-severe plaque psoriasis in patients 4 years and older.
Clinical overview from our editorial drug guide for Etanercept Injection. For billing reference, see the sections above.
🧾 Billing & reimbursement HCPCS · CMS
Medicare payment limit / unit
—
Est. ASP / unit
—
Est. after 2% sequester
—
HCPCS dosage
—
The CMS payment limit is the Medicare Part B drug allowance (ASP + 6%, statutory). After the 2% federal sequester the effective payment is ≈ ASP + 4.3%; estimated ASP = payment limit ÷ 1.06. Source: CMS Medicare Part B Payment Limit File (quarterly).
Full HCPCS code details (official CMS record)
Long descriptionInjection, etanercept, 25 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)
CoverageD — Special coverage instructions apply
Pricing indicator51 — Drug — priced under the ASP methodology
Type of service1 — Medical care
BETOS-2O1E
ASC payment groupYY
Action codeN — No maintenance this year
Effective date2000-01-01
Date added2000-01-01
Source: CMS HCPCS Level II code file (imported via admin).
🧮 Dosing & billing-units calculator HCPCS UNITS
One billing unit of J1438 = 1 unit. Enter a regimen to convert dose → billing units and project a full course.
Billing units = dose ÷ HCPCS unit size. Most payers require whole units — round per the payer's policy. “Est. Medicare pay” uses the current payment limit. For single-dose vials, drug discarded after administration may be separately billable with modifier JW (JZ when none is discarded) where allowed. Always verify payer-specific rounding before billing.
🔁 NDCs that bill under J1438 LEAST EXPENSIVE FIRST
19 NDCs map to J1438. Bill units = how many HCPCS units one package represents.
| NDC (11-digit) | Drug | Labeler | Package | Strength | Bill units | NADAC / unit | Status | Source |
|---|---|---|---|---|---|---|---|---|
| 58406-0021-04 | ENBREL etanercept 50 mg/mL SOLUTION | Immunex | 4 SYRINGE in 1 CARTON (58406-021-04) / 1... | 50 mg/mL | 2 | $2,080.680 | ● Active | PDAC |
| 58406-0044-04 | ENBREL etanercept 50 mg/mL SOLUTION | Immunex | 4 CARTRIDGE in 1 CARTON (58406-044-04) /... | 50 mg/mL | 2 | $2,081.000 | ● Active | PDAC |
| 58406-0032-04 | ENBREL etanercept 50 mg/mL SOLUTION | Immunex | 4 SYRINGE in 1 CARTON (58406-032-04) / 1... | 50 mg/mL | 2 | $2,083.620 | ● Active | PDAC |
| 58406-0010-04 | ENBREL etanercept 25 mg/.5mL SOLUTION | Immunex | 4 SYRINGE in 1 CARTON (58406-010-04) / .5... | 25 mg/.5mL | 2 | $2,086.200 | ● Active | PDAC |
| 58406-0055-04 | ENBREL etanercept 25 mg/.5mL SOLUTION | Immunex | 4 VIAL, SINGLE-DOSE in 1 CARTON (58406-055... | 25 mg/.5mL | 2 | — | ● Active | PDAC |
| 58406-0021-01 | ENBREL (50MG/1ML PREFILL SYR,PF) 50 MG/1 ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0032-01 | ENBREL (SURECLICK AUTOINJECTOR) 50 MG/1 ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0044-01 | ENBREL MINI (1 PREFILLED CARTRIDGE) 50 MG/1 ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0010-01 | ENBREL (25MG/0.5ML PREFILL SYR) 50 MG/1 ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0456-04 | ENBREL (MINI,PF) 50 MG/1 ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0456-01 | ENBREL (MINI,PF) 50 MG/1 ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0455-01 | ENBREL (27G,1/2",PF) 50 MG/ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0455-04 | ENBREL (4X0.51ML,27G,1/2",PF) 50 MG/ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0445-01 | ENBREL (SURECLICK AUTOINJECTOR) 50 MG/ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0445-04 | ENBREL (SURECLICK AUTOINJECTOR) 50 MG/ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0435-01 | ENBREL (ACTUAL FILL 50MG/0.98ML) 50 MG/ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0435-04 | ENBREL (ACTUAL FILL 50MG/0.98ML) 50 MG/ML | Unknown | — | — | 2 | — | — | PDAC |
| 58406-0425-41 | ENBREL (S.D. TRAY,PF) 25 MG | Unknown | — | — | 1 | — | — | PDAC |
| 58406-0425-34 | ENBREL (S.D. TRAY,PF) 25 MG | Unknown | — | — | 1 | — | — | PDAC |
NDC→HCPCS mappings come from the CMS ASP NDC-HCPCS crosswalk; additional DME MAC / DMEPOS mappings come from PDAC and are labeled separately. NADAC from CMS (weekly). “Status” reflects the product's marketing / obsolete flag in the NDC directory. Presence or absence here does not determine Medicare coverage. Linked NDCs open the full product page.
📈 Medicare Part B claims detail CMS PSPS · 2024
Calendar-year 2024 Medicare Part B fee-for-service activity for this HCPCS code, summed across all carriers, localities and specialties (CMS Physician/Supplier Procedure Summary). A “service” is one billed line/unit — not one claim — so counts run higher than claim counts.
Allowed charges
$0.00
Medicare paid
$0.00
Submitted services
525
Denial rate
100.0%
Submitted charges
$51.7K
Source: CMS Physician/Supplier Procedure Summary (PSPS), CY2024 — Medicare Part B carrier + DME fee-for-service claims (excludes Medicare Advantage). Figures are for the whole HCPCS code, which may cover uses beyond this drug. ⚠ CMS hides any figure covering fewer than 11 patients (a privacy rule), so totals — especially denials and low-volume codes — run a little low.
📊 What bills under J1438
J-codes are billing codes often used for drugs billed under the medical benefit. This connects the billing code to the NDC package records it covers, by ingredient and labeler.
NDC products by ingredient
NDC products by labeler
🗃️ Data sources & freshness
Every figure on this page is computed from public datasets. Here's what each section draws on and how current it is.
HCPCS code & descriptor
CMS HCPCS Level II code file
Loaded
Payment limit & billing unit
CMS Medicare Part B ASP Pricing File (quarterly)
Not available
NDC ↔ HCPCS crosswalk
CMS ASP NDC-HCPCS crosswalk + DMEPDAC (PDAC)
19 NDCs mapped
NADAC acquisition cost
CMS National Average Drug Acquisition Cost (weekly)
Available for mapped NDCs
Utilization & spend
CMS Part B Spending by Drug · PSPS · Physician & Other Practitioners
No reportable utilization
Figures are estimates for reference and may lag the source files. Always verify against the current CMS files and your payer's policy before submitting claims.
⚠️ Practical billing caveats
- A crosswalk is not coverage. An NDC mapping or a published payment limit does not guarantee a payer will cover or pay this code. Check the specific plan's policy.
- Units ≠ milligrams. Bill the number of HCPCS units (dose ÷ the code's unit size), not the milligram dose. Use the calculator above.
- Discarded drug. For single-dose vials, drug discarded after administration may be separately billable with modifier JW (and JZ when nothing is discarded) where the payer allows.
- Rounding & partial units. Many payers require whole units; round per the payer's policy, not automatically up.
- The code can cover more than this drug. Some HCPCS codes span multiple products or strengths — confirm the exact code for the product administered.
- Figures lag. ASP limits change quarterly and utilization data are released with a delay. Verify against the current CMS files before billing.
❓ J1438 billing FAQ
What is HCPCS code J1438?
J1438 is a HCPCS Level II J-code used to bill Injection, etanercept, 25 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) under Medicare Part B and most medical (not pharmacy) benefits.
Which NDCs bill under J1438?
19 NDCs currently map to J1438 in the CMS ASP NDC-HCPCS crosswalk. See the NDC crosswalk table above for each product, package, billing units and estimated reimbursement.
Does a crosswalk mean J1438 is covered?
No. An NDC-to-HCPCS crosswalk and a published payment limit do not guarantee coverage or payment. Coverage depends on the payer, the diagnosis and the site of care — always verify the current policy before billing.
For professional billing reference only — verify against the current CMS files before submitting claims.