N.J. Admin. Code § 10:54-9.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:54-9.1 - Introduction

(a) The New Jersey Medicaid program utilizes the Federal Centers for Medicare & Medicaid Services' (CMS) Healthcare Common Procedure Coding System (HCPCS), incorporated herein by reference, as amended and supplemented. Revisions to the Healthcare Common Procedure Coding System made by the CMS (code additions, code deletions and replacement codes) will be reflected in this chapter through publication of a notice of administrative change in the New Jersey Register. Revisions to existing reimbursement amounts specified by the Division and specification of new reimbursement amounts for new codes will be made through rulemaking in accordance with the Administrative Procedure Act, 52:14B-1 et seq. HCPCS follows the American Medical Association's Physician's Current Procedural Terminology architecture, employing a five-position code and as many as two 2-position modifiers. Unlike the CPT numeric design, the CMS assigned codes and modifiers contain alphabetic characters. HCPCS was developed as a three-level coding system.

1. Level I Codes: The narratives for these codes are found in CPT-4. CPT-4 is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians.

2. Level II Codes: The narratives for Level II codes are found in 10:54-9.10. These codes are not found in the CPT-4 and are assigned by HCFA for use by physicians and other practitioners.

3. Level III Codes: The narratives for Level III codes are found in 10:54-9.10. These codes are assigned by the Division of Medical Assistance and Health Services to be used for those services which are unique to the New Jersey Medicaid program.

(b) General policies regarding the use of HCPCS for procedures and services are listed below:

1. The responsibilities of physicians when rendering specific services is located in N.J.A.C. 10:54-1 through N.J.A.C. 10:54-8.

2. When filing a claim, the HCPCS procedure codes, including modifiers and qualifiers, must be used in accordance with the narratives in the CPT and the narratives and descriptions listed in this Subchapter 9, whichever is applicable.

3. The use of a procedure code, which describes the service, will be interpreted by the New Jersey Medicaid program, as evidence that the physician or practitioner personally furnished, as a minimum, the stated service. He or she will sign the claim as the servicing provider with the Medicaid Servicing Provider Number (MSPN) as evidence of the validity of the use of the procedure code reflecting the service provided.

4. Listed in the following sections are specific policies of the New Jersey Medicaid program relevant to HCPCS. This is to specifically call to the attention of physicians and practitioners the uniqueness of the policies in this subchapter and the need to incorporate these instructions when filing a claim for services provided to Medicaid recipients. (See also the Fiscal Agent Billing Supplement.)

5. Additional requirements of the provider when rendering specific services and requesting reimbursement are listed in the subchapters on prior authorization, recordkeeping, basis of payment, EPSDT, and other specific services.

N.J. Admin. Code § 10:54-9.1

Amended by R.2006 d.237, effective 7/3/2006.
See: 38 N.J.R. 907(a), 38 N.J.R. 2803(a).
Rewrote (a); in (b)2, substituted "the CPT" for "CPT-4".