N.J. Admin. Code § 10:58A-4.5

Current through Register Vol. 56, No. 16, August 19, 2024

Section 10:58A-4.5 - HCPCS procedure codes-qualifiers

HCPCS CODES

MOD

DESCRIPTIONS

(a) Surgical Services

11975 SA	QUALIFIER: Reimbursed for the
insertion or reinsertion of
implantable contraceptive capsules
and the post insertion visit when the
APN bills for the service.
11976 SA	QUALIFIER: The maximum fee
allowance is reimbursed for the
removal of implantable contraceptive
capsules and for the post removal
visit.
11977 SA	QUALIFIER: The maximum fee
allowance is reimbursed for the
removal and reinsertion of
implantable contraceptive capsules
and for the post-removal/reinsertion
visit.
HCPCS CODES	MOD	DESCRIPTIONS
E 29105 SA, E 29125 SA, E 29130 SA, E 29200 SA, E 29220 SA, E 29240 SA,		QUALIFIER: These
E 29260 SA, E 29280 SA, E 29505 SA, E 29515 SA, E 29520 SA, E 29530 SA, E		HCPCS are excluded
29540 SA, E 29550 SA, E 29580 SA, E 29590 SA, E 29700 SA, E 29705 SA, E 29710		from multiple
SA, E 29715 SA, E 29720 SA, E 29730 SA, E 29740 SA, E 31720 SA, E 36415 SA, E		surgical pricing and
57150 SA, E 58300 SA, E 58301 SA, E 59025 SA, E 59430 SA		as such shall be
		reimbursed like the
		primary procedure at
		100 percent of the
		program maximum fee
		allowance even when
		the procedure is
		performed on the
		same beneficiary, by
		the same provider,
		at the same session.
(b) Laboratory services:
36415 SA	QUALIFIER: Once per visit, per
patient
(c) Immunizations:
N 90746	QUALIFIER: This applies only to
high risk beneficiaries over 19 years
of age.
90465, 90466,	QUALIFIER: These codes apply only
90467, 90468, 90471,	to the administration of vaccines to
90472, 90473, 90474	beneficiaries under 19 years of age
who qualify for the Vaccine for
Children (VFC) program. See N.J.A.C.
10:58A-2.13 and 4.2(k).

(d) Infusion therapy (excluding allergy, immunizations and chemotherapy):

96360 SA	QUALIFIER: Not to be used for
routine IV drug injection or
infusion.
96361 SA	QUALIFIER: Not to be used for
routine IV drug injection or
infusion.

(e) Therapeutic or diagnostic injections:

There are no qualifiers for therapeutic or diagnostic injections.

(f) Mental health services:

		QUALIFIER: Only under exceptional circumstances
		will more than one mental health procedure be reimbursed
		per day for the same beneficiary by the same APN, group
		of APNs shared health facility, or providers sharing a
		common record. When circumstances require more than one
		mental health procedure, the medical necessity for the
		services shall be documented in the patient's chart.
HCPCS CODES	MOD	DESCRIPTIONS
90801 SA	24.70
		QUALIFIER: This code requires for reimbursement
		purposes a minimum of 50 minutes of direct personal
		clinical involvement with the patient or family member.
90804 SA	Individual	12.40
Psychotherapy-- 25
minute session
		QUALIFIER: This code requires for reimbursement
		purposes a minimum of 25 minutes of direct personal
		clinical involvement with the patient or family member.
90805 SA	QUALIFIER: This code requires
for reimbursement purposes a minimum
of 25 minutes direct personal clinical
involvement with the patient or
family, including medicine evaluation
and management services.
90806 SA	Individual	24.70
Psychotherapy--50
minute session
QUALIFIER: This code requires
for reimbursement purposes a minimum
of 50 minutes of direct personal
clinical involvement with the patient
or family member.
90807 SA	24.70
		QUALIFIER: This code requires for reimbursement
		purposes a minimum of 50 minutes direct personal clinical
		involvement with the patient or family, including
		medicine evaluation and management services.
90847 SA	Family Therapy--50	24.70
minute session
		QUALIFIER: This code requires, for reimbursement
		purposes, a minimum of 50 minutes of direct personal
		clinical involvement with the patient or family member.
90847 SA 22	Family Therapy--80	30.40
minute session
		QUALIFIER: This code requires, for reimbursement
		purposes, a minimum of 80 minutes of direct personal
		clinical involvement with the patient or family member.
90887 SA	Family	12.40
Conference--25 minute
session
		QUALIFIER: This code requires, for reimbursement
		purposes, a minimum of 25 minutes of direct personal
		clinical involvement with the patient or family member.
		The CPT narrative otherwise remains applicable.

(g) Evaluation and management services:

1. Office or other outpatient services: new patient

99201 SA, 99202 SA

99203 SA, 99204 SA

i. QUALIFIER: An initial office visit, or an initial residential health care visit, is limited to a single visit. Future use of this category of codes will be denied when the beneficiary is seen by the same clinical practitioner, group of clinical practitioners, or member of the same shared health care facility.

ii. QUALIFIER: HCPCS procedure codes 99201 SA and 99202 SA are exceptions to the requirements outlined in the qualifier for the initial visit. For the codes 99201 SA and 99202 SA, the provider is expected to follow the qualifier applied to routine visit or follow-up care visit for reimbursement purposes.

iii. QUALIFIER: As described at 10:58A-1.4, Evaluation and Management services pertain to patients presenting with symptoms, and as such, exclude Preventive Health Care. Preventive services for patients including newborns through persons 20 years of age are billed under EPSDT, when the procedure requirements are met, as described at 10:58A-2.11.

99221 SA	Hospital inpatient services: initial
hospital care
99301 SA, 99302 SA, 99303 SA,	Nursing facility services, initial
99321 SA, 99322 SA	care, new or established patient
Domiciliary or rest home services: new
patient
99341 SA, 99342 SA, 99343 SA,	Home visit: new patient
99344 SA, 99345 SA

iv. QUALIFIER: When reference is made in the CPT manual to the procedures listed above, the intent of the Medicaid and NJ FamilyCare fee-for-service programs is to consider this service as the Initial Visit.

v. QUALIFIER: Reimbursement for an initial office visit or initial residential health care facility visit will be disallowed, if a preventive medicine service, EPSDT examination or office consultation were billed within a twelve month period by a clinical practitioner, group, shared health care facility, or clinical practitioners sharing a common record.

vi. QUALIFIER: In reference to a nursing facility or hospital, the Initial Visit concept will still apply for reimbursement purposes. Subsequent readmissions to the same facility may be reimbursed as Initial Visits, if the readmission occurs more than 30 days from a previous discharge from the same facility by the same provider. When the readmission occurs within 30 days from a previous discharge, the provider shall bill the relevant HCPCS procedure codes specified under the headings Subsequent Hospital Care or Subsequent Nursing Facility Care.

vii. QUALIFIER: Initial Hospital Visit during a single admission will be disallowed to the same clinical practitioner, group, shared health care facility, or clinical practitioners sharing a common record who submit a claim for a consultation and transfer the patient to their service.

2. Follow-up visit:

99212 SA, 99213 SA,	Office or other outpatient services:
99214 SA, 92215 SA,	established patient;
99231 SA, 99232 SA,	Hospital inpatient services: subsequent
hospital care;
99311 SA, 99312 SA	subsequent hospital care;
99313 SA, 99238 SA	Nursing facility services subsequent
nursing facility care;
subsequent nursing facility care;
99331 SA, 99332 SA,	Domiciliary, rest home or
99333 SA, 99347 SA,	custodial care services: established
99348 SA, 99349 SA,	patient; and
99350 SA	Home visit: established patient

i. QUALIFIER: When reference is made in the CPT manual to the services specified above, the intent of Medicaid and NJ FamilyCare fee-for-service is to consider this service as the Routine Visit or Follow Up Care visit. The setting could be an office, hospital, nursing facility, the beneficiary's home or residential health care facility.

(h) Preventive Medicine Services: Annual Health Maintenance Examination

1. New Patient	Established Patient
99382 SA	99392 SA
99383 SA	99393 SA
99384 SA	99394 SA
99385 SA	99395 SA
99386 SA	99396 SA
99387 SA	99397 SA

QUALIFIER: Preventive medicine services codes (new patient) 99382, 99383, 99384, 99385, 99386, and 99387 may only be billed once within 12 months when the beneficiary is seen by the same clinical practitioner, group of clinical practitioners sharing a common record, or member(s) of a shared health care facility. These codes will also be automatically denied for payment when used following an EPSDT examination performed within the preceding 12 months.

QUALIFIER: Preventive medicine services codes (established patient) 99392, 99393, 99394, 99395, 99396 and 99397 may be used only once in a 12-month period for any individual over two years of age. For well-child care provided to children under the age of two, it is suggested that the provider bill for an EPSDT examination.

QUALIFIER: Preventive medicine services code 99392 may be used up to 5 times during the patient's first year of life and up to 3 times during the patient's second year of life, respectively, in accordance with the periodicity schedule of preventive visits recommended by the American Academy of Pediatrics. This code does not apply to children under 2 years of age participating in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. EPSDT providers bill for these services using the program appropriate codes 99381 22, 99391 22, 99382 22, 99392 22 (Infant, age under 1 year) or 99381 22 EP, 99391 22 EP, 99382 EP, 99392 22 EP (Early childhood, age 1 through 4 years).

2. Preventive medicine services codes (established patient) 99392, 99393, 99394, 99395, 99396 and 99397 may be used only once in a 12-month period for any individual over 2 years of age. For well-child care provided to children under the age of two, it is suggested that the provider bill for an EPSDT examination.

3. Preventive medicine services code 99391 and 99392 may be used up to five times during the patient's first year of life and up to three times during the patient's second year of life respectively, in accordance with the periodicity schedule of preventive visits recommended by the American Academy of Pediatrics. These codes do not apply to children under two years of age participating in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. EPSDT providers bill for these services using the program appropriate codes 99381 22, 99391 22, 99382 22, 99392 22 (Infant, age under 1 year) or 99381 22 EP, 99391 22 EP, 99382 22 EP, 99392 22 EP (Early childhood, age 1 through 4 years).

(i) Home Services and House Calls:

The "House Call" code does not distinguish between specialist and non-specialist. These codes do not apply to residential health care facility or nursing facility settings. These codes refer to a clinical practitioner visit limited to the provision of medical care to an individual who would be too ill to go to a clinical practitioner's office and/or is "home bound" due to his or her physical condition. When billing for a second or subsequent patient treated during the same visit, the visit should be billed as a home visit.

99341 SA, 99342 SA	19.60	19.60
99344 SA, 99345 SA	48.90	48.90
99347 SA, 99348 SA,	33.30	48.90
99349 SA, 99350 SA	48.90	48.90

For purposes of Medicaid/NJ FamilyCare fee-for-service reimbursement, these codes apply when the provider visits Medicaid/NJ FamilyCare fee-for-service beneficiaries in the home setting and the visit does not meet the criteria specified under House Call listed above.

(j) Emergency room services:

APN's Use of Emergency Room Instead of Office:

99211 SA, 99212 SA, 99213 SA, 99214 SA

When an APN sees the patient in the emergency room instead of the office, the APN shall use the same codes for the visit that would have been used if seen in the APN's office (99211, 99212, 99213, 99214 or 99215 only). Records of that visit should become part of the notes in the office chart.

99281 SA, 99282 SA, 99283 SA, 99284 SA

Emergency room visits (Refer to the CPT) Hospital-based emergency room APNs:

When patients are seen by hospital-based emergency room APNs who are eligible to bill the Medicaid/NJ FamilyCare fee-for-service program, the appropriate HCPCS code is used. The "Visit" codes are limited to 99281 SA, 99282 SA, 99283 SA, 99284 SA and 99285 SA.

(k) Newborn care:

99460 SA,	Routine and subsequent hospital newborn
99462 SA, 99463	care--"Well" baby
SA, 99464 SA,
99465 SA

QUALIFIER: For reimbursement purposes, the above codes require, as a minimum, routine newborn care by an APN other than the clinical practitioner rendering maternity service, including complete initial and complete discharge physical examination, conference(s) with the patient(s). This must be documented in the newborn's medical record.

Newborn care--"Sick" baby
99221 SA	Initial hospital care
99231 SA	Subsequent hospital care
99232 SA	(For sick babies, use appropriate
hospital care code.)

(l) Early and Periodic Screening

99381 SA-	Diagnosis and Treatment
99385 SA or	(EPSDT) through age 20
99391 SA-
99395 SA

QUALIFIER: Procedure codes 99381 SA through 99385 SA or 99391 SA through 99395 SA shall be used only once for the same patient during any 12-month period by the same clinical practitioner(s) sharing a common record.

QUALIFIER: Reimbursement for codes 99381 EP through 99385 EP or 99391 EP through 99395 EP (under age 1 or age 1 through 19 years) is contingent upon the submission of both a completed "Report and Claim for EPSDT Screening and Related Procedures (MC-19)" within 30 days of the date of service. In the absence of a completed MC-19 form, reimbursement will be to the level of an annual health maintenance examination.

N.J. Admin. Code § 10:58A-4.5

Amended by R.2000 d.144, effective 4/3/2000.
See: 31 N.J.R. 3968(a), 32 N.J.R. 1208(a).
Rewrote (a), (h) and (j); in (c), inserted a reference to W9356; in (f), (g), (k) and ( l), changed procedure code references throughout; and in (k), substituted references to practitioners for references to physicians throughout, and substituted a reference to CPT for a reference to CPT-4.
Amended by R.2000 d.265, effective 7/3/2000.
See: 32 N.J.R. 1127(a), 32 N.J.R. 2483(a).
Rewrote the section.
Amended by R.2004 d.409, effective 11/1/2004.
See: 35 N.J.R. 4977(a), 36 N.J.R. 4968(a).
Rewrote the section.
Amended by R.2005 d.406, effective 11/21/2005.
See: 37 N.J.R. 2329(a), 37 N.J.R. 4445(a).
Rewrote the section.
Amended by R.2007 d.188, effective 6/18/2007.
See: 39 N.J.R. 337(a), 39 N.J.R. 2360(a).
In the table in (f), in the Qualifier paragraph for the entry for 90801 SA, deleted the final sentence.
Amended by R.2011 d.119, effective 4/18/2011.
See: 42 N.J.R. 2890(a), 43 N.J.R. 1015(a).
Rewrote the section.