Retrograde approach using cystoscope

Code	Description
52005	Cystourethroscopy, with ureteral catheterization
74420*	Urography, retrograde, with or without KUB
J9281	Mitomycin pyelocalyceal instillation, 1 mg
J9281-JW	JW modifier for wastage

* If performed

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Antegrade approach via nephrostomy tube

Code	Description
50391	Instillation of therapeutic agent into renal pelvis and/or ureter through established nephrostomy tube
50431*	Injection procedure for antegrade nephrostogram and/or ureterogram…; existing access
74420*	Urography, retrograde, with or without KUB
J9281	Mitomycin pyelocalyceal instillation, 1 mg
J9281-JW	JW modifier for wastage

* If performed

Code	Description
C65.1	Malignant neoplasm of right renal pelvis
C65.2	Malignant neoplasm of left renal pelvis
C66.9	Malignant neoplasm of unspecified ureter
C66.1	Malignant neoplasm of right ureter
C66.2	Malignant neoplasm of left ureter
C68.9	Malignant neoplasm of urinary organ, unspecified

• Document the amount administered and the amount discarded/wasted (separate line or note).
• Include route of administration (retrograde ureteral catheter vs nephrostomy tube) and any applicable imaging performed.

• JW modifier: use J9281-JW to report discarded drug (wastage) when applicable.
• Dose math reminder: JELMYTO is 4 mg/mL once reconstituted; bill units based on mg instilled and report the remainder with JW when allowed.
• Ancillary codes: additional imaging/ancillary services may apply depending on what is performed and payer rules.
• Payer variation: verify payer coverage rules, diagnosis limitations, and site-of-service requirements prior to treatment.

ASC (Ambulatory Surgical Center) — Medicare fee-for-service (when applicable)

• J9281 — Mitomycin pyelocalyceal instillation, 1 mg
• J9281-JW — JW modifier for wastage
• C9789 — Instillation of anti-neoplastic pharmacologic/biologic agent into renal pelvis, any method, including all imaging guidance, including volumetric measurement if performed (Medicare FFS HOPD/ASC context)

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HOPD (Hospital Outpatient Department) — Medicare fee-for-service (when applicable)

• J9281 — Mitomycin pyelocalyceal instillation, 1 mg
• J9281-JW — JW modifier for wastage
• C9789 — Instillation of anti-neoplastic pharmacologic/biologic agent into renal pelvis, any method, including all imaging guidance, including volumetric measurement if performed

Note: Payer policies vary. Confirm whether C9789 is appropriate for the specific payer and setting; contracts and fee schedules should be verified to ensure adequate reimbursement.

Code	Description
C65.9	Malignant neoplasm of unspecified renal pelvis
C65.1	Malignant neoplasm of right renal pelvis
C65.2	Malignant neoplasm of left renal pelvis
C66.9	Malignant neoplasm of unspecified ureter
C66.1	Malignant neoplasm of right ureter
C66.2	Malignant neoplasm of left ureter
C68.9	Malignant neoplasm of urinary organ, unspecified

UB-04 (CMS-1450) – common required elements (HOPD)

• Revenue code (FL 42): report per hospital billing policy for drug/detail lines and procedure/services.
• Drug detail (FL 43): include N4 + 11-digit NDC + unit qualifier + unit quantity.
• HCPCS/procedure/units (FL 44–46): include J9281 (and JW line as applicable), plus procedure code for instillation as appropriate; report service units.
• Diagnosis (FL 66): report ICD-10-CM for LG-UTUC being treated.
• Remarks (FL 80): include drug name, quantity administered, route (ureteral catheter vs nephrostomy tube), and NDC as needed; some payers require the route and/or separate attachment.

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Units & wastage (facility reminder)

• Reconstituted concentration is 4 mg/mL. Bill J9281 units based on mg instilled (4 mg per mL).
• For remaining mg not instilled, report wastage using J9281 with JW when allowed.
• Include amount administered and amount wasted in documentation/claim detail when required.

• Site of care matters: billing rules differ for Physician Office vs ASC vs HOPD, and by payer.
• C9789 context: confirm payer applicability (often tied to Medicare fee-for-service HOPD/ASC context).
• Contract verification: for Medicare Advantage / Commercial / Managed Medicaid, verify fee schedules and whether drug is separately reimbursed for your site of service.
• Payer policy checks: confirm diagnosis limitations, prior auth requirements, and claim form preferences (some payers may require additional attachments or route/basis of measurement).