N.J. Admin. Code § 10:54-9.8

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

Section 10:54-9.8 - HCPCS Procedure Codes with Qualifiers (except for Pathology/Laboratory)

(a) The following is a list of Level I HCPCS procedure codes with their associated qualifiers (except for Pathology and Laboratory procedure codes). Providers are to recognize the requirements inherent in billing each of the HCPCS. The qualifiers related to Pathology/Laboratory Services are located in the next section in 10:54-9.9. FOR A LISTING OF QUALIFIERS FOR THE EVALUATION AND MANAGEMENT PROCEDURE CODES, SEE (e) OF THIS SUBCHAPTER.

Code	Narrative
10040	Acne surgery (e.g. marsupialization, opening or removal of
multiple milia, comedones, cysts, pustules)
QUALIFIER: This code is limited to severe acne; for less severe
acne, utilize procedure codes for routine office visit. Excision
must involve the use of a scalpel and an expresser but not an
expresser alone.
11975	Insertion, implantable contraceptive capsules.
QUALIFIER: The maximum fee allowance is reimbursed for the
insertion or reinsertion of the "Norplant System" (six
levonorgestrel implants) and the post insertion visit when
provided in a hospital setting, when the physician bills for the
service. When using this procedure code, the physician will not
be reimbursed for the cost of the kit. The supplier of the kit
to the physician will be reimbursed directly for the cost of the
kit.
11975 22	Insertion, implantable contraceptive capsules.
QUALIFIER: The maximum fee allowance is reimbursed includes the
cost of the kit supplied to the physician, the insertion of the
"Norplant System" (six levonorgestrel implants) and the post
insertion visit. NOTE: The "22" modifier indicates the inclusion
of the cost of the kit.
11976	Removal of implantable contraceptive capsules.
QUALIFIER: The maximum fee allowance is reimbursed for the
removal of the "Norplant System" (six levonorgestrel implants)
and for the post removal visit.
11977	Removal of implantable contraceptive capsules.
QUALIFIER: The maximum fee allowance is reimbursed for the
removal of the "Norplant System" (six levonorgestrel implants).
11977 22	Removal with reinsertion, implantable contraceptive capsules.
QUALIFIER: The maximum fee allowance is reimbursed for the
removal and reinsertion of the "Norplant System" (six
levonorgestrel implants) and for the post removal/reinsertion
visit. NOTE: Modifier "22" indicates that the billing includes
the cost of the NPS kit.
36510	Catheterization of umbilical vein for diagnosis or therapy;
newborn.
QUALIFIER: May be used in addition to a Hospital Inpatient
Services or Inpatient Consultation procedure codes, if
applicable, but not in addition to Critical Care or Prolonged
Detention procedure codes.
36660	Catheterization of umbilical artery, newborn, for diagnosis or
therapy.
QUALIFIER: May be used in addition to a Hospital Inpatient
Services or Inpatient Consultation procedure codes, if
applicable, but not in addition to Critical Care or Prolonged
Detention procedure codes.

(b) Diagnostic endoscopy: The following are the qualifiers for HCPCS procedure codes for diagnostic endoscopic procedure codes.

1. Respiratory System (CPT codes 30000-32999)

31520	Laryngoscopy direct, with or without tracheoscopy; diagnostic
newborn.
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
31525	Laryngoscopy direct, with or without tracheoscopy; diagnostic
except newborn.
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
31575	Laryngoscopy, flexible fiberoptic; diagnostic
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
31615	Tracheobronchoscopy through established tracheostomy incision.
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
31622	Diagnostic (flexible or rigid) with or without all washing or
brushing.
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".

2. Hemic and Lymphatic systems (CPT codes 38100-39599)

39400 22	Mediastinoscopy with biopsy
QUALIFIER: Multiple surgery pricing applies.

3. Digestive system (CPT codes 40490-49999)

i. Upper gastrointestinal system

43200	Esophagoscope, rigid or flexible; diagnostic, with or without
removal of foreign body
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
43234	Upper gastrointestinal endoscopy simple primary examination
(e.g. with small diameter flexibile fiberscope)
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
43235	Upper gastrointestinal endoscopy including esophagus, stomach
and either the duodenum and/or jejunum, as appropriate; complex
diagnostic
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".

ii. Lower gastrointestinal

45300	Proctosigmoidoscopy; diagnostic (separate procedure)
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
45330	Sigmoidoscopy, flexible fiberoptic; diagnostic
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
46600	Anoscope: diagnostic (separate procedure)
QUALIFIER: This diagnostic endoscopy procedure has the least
penetration: (despite the "high" HCPCS number). When combined
with another endoscopic procedure in the same body system, the
reimbursement is at the rate of the maximum fee allowance of any
other procedure code that denotes the "deepest penetration".

iii. Biliary tract;

47550	Biliary endoscopy, intraoperative (kaleidoscope)
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
47552	Biliary endoscopy, intraoperative (kaleidoscope)
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.

iv. Urinary system (CPT codes 50010-53899)

50951	Ureteral endoscopy through established ureterostomy, with or
without irrigation, instillation, or ureteropyelography,
exclusive of radiologic service
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
50970	Ureteral endoscopy through ureterotomy, with or without
irrigation, instillation, or ureteropyelography, exclusive of
radiologic service
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
52000	Cystourethroscopy (separate procedure)
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.

v. Female genital system (CPT codes 56000-58999)

57452	Colposcopy (vaginoscopy); (separate procedure)
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.

(c) HCPCS Code Qualifiers

41872	Gingivoplasty
QUALIFIER: Reimbursement is based upon a dollar amount for each
quadrant.
50590	Lithotripsy, extracorporeal shock wave (Professional Component)
(PC)
QUALIFIER: For the Professional Component of lithotripsy,
extracorporeal shock wave (ESWL), reimbursement includes all
professional services (Professional Component pertaining to ESWL
performed by the treating physician during this hospitalization,
consortium visit or office visit. This code excludes
reimbursement of the Technical Component of the ESWL service.
55250	Vasectomy, unilateral or bilateral (separate procedure),
including postoperative semen examination(s)
QUALIFIER: As a primary sterilization (family planning
procedure), a completed consent form must be attached to the
1500 N.J. claim form. See 10:54-5.16 for regulations on
sterilizations and hysterectomy.
55450	Ligation (percutaneous) of vas deferens, unilateral or bilateral
(separate procedure)
QUALIFIER: As a primary sterilization (family planning
procedure), a completed consent form must be attached to the
1500 N.J. claim form. See 10:54-5.16 for regulations on
sterilization and hysterectomy.
58301 WM	Removal of intrauterine device by certified nurse midwife.
58611	Ligation or transection of fallopian tube(s) when done at the
time of obstetrical delivery (caesarean section) or
intra-abdominal surgery (not a separate procedure)
QUALIFIER: This procedure code may be billed separately in
addition to the appropriate procedure codes for primary
obstetrical or abdominal surgery procedure. This also includes
those obstetrical procedure codes used by HealthStart identified
providers.
59510	Caesarean delivery only including postpartum care
59514	QUALIFIER: For anesthesia during Caesarean Section,
59515	use Anesthesia reimbursement methodology including the AA
modifier and indicating the standard anesthesia formula (time in
units of 15 minute intervals) when used in combination with
HCPCS 62278 or 62279.
62278	Injection of anesthesia substance (including narcotics),
diagnostic or therapeutic; epidural, lumbar or caudal, single
QUALIFIER: Only for use during labor or intractable pain,
(including insertion of catheter or cannula--lumbar or
caudal--single, regardless of time).
62279	Injection of anesthesia substance (including narcotics),
diagnostic or therapeutic; epidural, lumbar or caudal,
continuous
QUALIFIER: Only for use during labor or intractable pain,
(including insertion of catheter or cannula--lumbar or caudal--
continuously, regardless of time). Reimbursement is at a flat
fee unless C-Section is necessary; then, separate reimbursement
for the C-Section and anesthesia using the anesthesia
reimbursement formula is allowed. This procedure code may be
used with HCPCS 59515.
66170	Fistula of sclera for glaucoma; trephination with iridectomy;
trabeculectomy QUALIFIER: This procedure code may be billed with
the following other procedure codes representing other optical
procedure (HCPCS 65850, 66030, 66625, and 67500) and be
reimbursed according to the multiple surgical policy.
66920	Discission of secondary membranous cataract
QUALIFIER: This procedure code must not be billed with any other
procedure code representing any other optical procedure.
66930	Removal of secondary membranous cataract
QUALIFIER: This procedure code must not be billed with any other
procedure code representing any other optical procedure.
66940	Removal of lens material; aspiration techniques, one or more
stages.
QUALIFIER: This procedure code must not be billed with any
other procedure code representing any other optical procedure.
67221	Photodynamic therapy
QUALIFIER: This procedure code may be billed with 67225. This
procedure code must be rendered by ophthalmologists who are
retinal specialists, and shall be limited to patients meeting the
following criteria:
Best corrected visual acuity equal to or better than 20/200 if
the decreased visual acuity is caused by the macular
degeneration; and Classic subfoveal choroidal neovascularization
(CNV), occupying 50 percent or greater of the entire ocular
lesion; and for dates of service before October 1, 2015, a
reported ICD-9-CM diagnosis of 115.02, 115.92, 362.21, or 362.52
(exudative senile macular degeneration) or for dates of service
on or after October 1, 2015, a reported ICD-10-CM diagnosis of
H35.32 or B39.9 w/H32.
NOTE: Report HCPCS procedure code 67225 on the CMS 1500 claim
form for procedures performed on a second eye when both eyes are
treated on the same date of service. Evaluation and management
(E& M) services, fluorescent angiography (FA) and other ocular
diagnostic services may also be billed separately when
determined medically necessary and provided on the same date of
service. Modifiers LT or RT should be used on all claims for
codes 67221 and 67225, whether initial or subsequent treatment.
67225	Photodynamic therapy, second eye, at single session
QUALIFIER: This procedure code must be billed with 67221. This
procedure code must be rendered by ophthalmologists who are
retinal specialists, and shall be limited to patients meeting the
following criteria:
Best corrected visual acuity equal to or better than 20/200 if
the decreased visual acuity is caused by the macular
degeneration; and
Classic subfoveal choroidal neovascularization (CNV), occupying
50 percent or greater of the entire ocular lesion; and for dates
of service before October 1, 2015, a reported ICD-9-CM diagnosis
of 115.02, 115.92, 362.21, or 362.52 (exudative senile macular
degeneration) or for dates of service on or after October 1,
2015, a reported ICD-10-CM diagnosis of H35.32 or B39.9 w/H32.
NOTE: Report HCPCS procedure code 67225 on the CMS 1500 claim
form for procedures performed on a second eye when both eyes are
treated on the same date of service. Evaluation
and management (E&M) services, fluorescent angiography (FA) and
other ocular diagnostic services may also be billed separately
when determined medically necessary and provided on the same
date of service. Modifiers LT or RT should be used on all
claims for codes 67221 and 67225, whether initial or subsequent
treatment.
69930	Cochlear device implantation, with or without mastoidectomy
QUALIFIER: Reimbursement limited to those cases that meet the
current Medicare Selection Criteria.
70470 52	Limited computerized axial tomography, head or body
70482 52	for medical necessary follow-up or monitoring
70488 52	QUALIFIER: For C.A.T. scan guidance (monitoring)
70492 52	performed in conjunction with biopsy, aspiration, puncture,
71270 52	injection of contrast material, placement of tube
74170 52	stint, drain, etc. use codes with modifier "52".

(d) Magnetic Resonance Imaging (MRI) Diagnostic Services:

QUALIFIER: An MRI service provided by physicians in an office
setting may be billed to and reimbursed by Medicaid only when
the recipient is other than a hospital inpatient. The Medicaid
Maximum Fee Allowance is the composite rate and shall not be
split between the technical component and the professional
component. These rules apply to the billing of the HCPCS for MRI
as follows:
70540	72148
70551	72156
70552	72157
70553	72158
71550	72196
72141	72220
72142	73720
72146	73721
72147	74181

72170	Radiologic examination, pelvis; anteroposterior only
QUALIFIER: Pelvis x-ray is not eligible for separate payment
when performed in conjunction with complete lumbarsacral spine
x-rays (72100, 72110, 72114, 72120)
76805	Echography, pregnant uterus, B-scan and/or real time with image
documentation; complete (complete fetal and maternal evaluation)
QUALIFIER: Limited to one complete study per pregnancy per
provider. Any additional medically necessary studies performed
by the same provider will be reimbursed as HCPCS 76815 (limited
study). Also, only one study (complete or limited or follow-up)
can be reimbursed to the same provider on a given day.
76815	Echography, pregnant uterus, B-scan and/or real time with image
documentation; limited (gestational age, heart beat, placental
location, fetal position, or emergency in the delivery room.)
QUALIFIER: Subsequent to the third study, a statement of medical
necessity attesting that the pregnancy is high risk with
substantiating reasons is required to be attached to the claim.
Only one study (complete or limited or follow-up) can be
reimbursed to the same provider on a given day.
76816	Echography, pregnant uterus, B-scan and/or real time with image
documentation; follow-up or repeat
QUALIFIER: Subsequent to the third study, a statement of medical
necessity attesting that the pregnancy is high risk with
substantiating reasons is required to be attached to the claim.
Only one study (complete or limited or follow-up) can be
reimbursed to the same provider on a given day.
77790	Supervision, handling and loading radioelement
QUALIFIER: Reimbursable only when performed by a Radiologist.
78805	Radionuclide localization of abscess: limited area
QUALIFIER: Reimbursable only when performed by a Radiologist.
***	FOR QUALIFIERS FOR PATHOLOGY AND LABORATORY SERVICES PROCEDURE
CODES, SEE THE SECTION OF THIS SUBCHAPTER AT N.J.A.C 10:54-9.9.
****	FOR QUALIFIERS FOR PREADMISSION SCREENING AND ANNUAL RESIDENT
REVIEW (PASARR), SEE THE SECTION OF THIS SUBCHAPTER AT N.J.A.C.
10:54-9.10.
90741	Immunization, passive; Immune serum globulin, human (ISG)
QUALIFIER: Prior authorization from the Medical Consultant at
the Medicaid District Office is required.
90742	Immunization, passive; Specific hyperimmune serum globulin,
human (ISG); e.g. hepatitis B, measles, pertussis, rabies,
Rho(D), tetanus, vaccinia, varicella zoster
QUALIFIER: Prior authorization from the Medical Consultant at
the Medicaid District Office is required.
90780	IV infusion therapy, (excluding allergy, immunizations and
chemotherapy) administered by physician exclusive of his/her
other duties or under direct supervision of physician by a
practitioner; up to one hour
QUALIFIER: Not to be used for routine IV drug injection or
infusion. Reimbursement is contingent upon the required medical
necessity, hand written chart documentation including time and
indication of physician's presence with the patient to the
exclusion of his other duties.
90781	IV infusion therapy, (excluding allergy, immunization and
chemotherapy) administered by physician exclusive of his or her
other duties or under direct supervision of physician; each
addition hour after first hour, up to eight hours
QUALIFIER: Not to be used for routine IV drug injection or
infusion. Reimbursement is contingent upon the required medical
necessity, hand written chart documentation including time and
indication of physician's presence with the patient to the
exclusion of his or her other duties.
90799	Unlisted therapeutic or diagnostic injection (For allergy
immunization, see HCPCS 95000 et seq.)
QUALIFIER: This procedure code may be used for intradermal,
subcutaneous, or intra arterial injections. Reimbursement is on
a flat fee basis and are all inclusive for the cost of the
service and the materials. (See also N.J.A.C. 10:54 for
reimbursement using "J" codes.) Intravenous and intra-arterial
injections are reimbursable only when performed by the
physician.
90801	Initial Comprehensive Psychiatric Evaluation
DESCRIPTION: Psychiatric diagnostic interview examination
including history, mental status or disposition (may include
communication with family or other sources, ordering medical
interpretation of laboratory or other medical diagnostic
studies. In circumstances other informants will be seen in lieu
of the patient.)
QUALIFIER: This code requires for reimbursement purposes a
minimum of 50 minutes of direct clinical involvement with the
patient or family member.
90830	Psychological testing, by physician, with a written report, per
hour
QUALIFIER: One unit is equal to 1 hour of psychological testing.
90843	Individual Psychotherapy--20-30 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.
90844	Individual Psychotherapy--45-50 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.
90847	Family Therapy--50 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.
90847 22	Family Therapy--80 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.
90853	Group medical psychotherapy (other than of a multiple-family
group) by a physician, with continuing medical diagnostic
evaluation and drug management when indicated
QUALIFIER: Psychotherapy Group (maximum 8 persons per group: 90
minutes, per person, per session.)
90887	Family 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.
92568	Acoustic reflex testing
QUALIFIER: Must include at least two (2) frequencies per ear.
92977	Thrombolysis, coronary; by intravenous infusion
QUALIFIER: Reimbursable only when performed by a physician whose
personal involvement would include the exclusion of all other
duties and services.
97799	Physical therapy
QUALIFIER: This procedure code may be used for the initial
evaluation for physical therapy in the home or for physical
therapy in a physicians office or independent clinic. Must not
be used for continuing physical therapy in the home or in
hospital inpatient or outpatient settings.
99082	Unusual travel (e.g. transportation and escort of patient)
QUALIFIER: This procedure code may be used for travel costs only
associated and billed with HOUSE CALL or HOME VISIT. (See
procedure codes 99341, 99341WM, 99342, 99342 WM, 99343, 99351,
99351WM, 99352, 99352 WM, 99353.
99190	Assembly and operation of pump with oxygenator or heat exchanger
(with or without ECG and/or pressure monitoring); each hour
QUALIFIER: Reimbursable only when personally performed by a
physician.
99191	Assembly and operation of pump with oxygenator or heat exchanger
(with or without ECG and/or pressure monitoring); 3/4 hour
QUALIFIER: Reimbursable only when personally performed by a
physician.
99192	Assembly and operation of pump with oxygenator or heat exchanger
(with or without ECG and/or pressure monitoring); 1/2 hour
QUALIFIER: Reimbursable only when personally performed by a
physician.

(e) The following statements and qualifiers apply to the "Evaluation and Management" procedure codes (HCPCS 99201-99499).

OFFICE OR OTHER OUTPATIENT SERVICES--NEW PATIENT; HOSPITAL INPATIENT SERVICES--INITIAL HOSPITAL CARE; NURSING FACILITY SERVICES--COMPREHENSIVE NURSING FACILITY ASSESSMENTS; AND DOMICILIARY, REST HOME, OR CUSTODIAL CARE SERVICES--NEW PATIENT

(Excludes Preventive Health Care for patients through 20 years of age.)

99201
99202	When reference is made in your CPT manual to Office or
99203	Other Outpatient Services--New Patient; Hospital Inpatient
99204	Services--Initial Hospital Care; Nursing Facility
99205	Services--Comprehensive Nursing Facility Assessments;
99221	and Domiciliary, Rest Home, or Custodial Care Services-New
99222	Patient; the intent of Medicaid is to consider
99223	this service as the Initial Visit.
99301	When the setting for this Initial Visit is an office or
99302	residential health care facility, for reimbursement purposes
99303	it is limited to a single visit. Future use of this category
99321	of codes will be denied when the recipient is seen
99322	by the same physician, group of physicians, or involves a
99323	shared health care facility which is a group of physicians
sharing a common record. Reimbursement for an initial office
visit also precludes subsequent reimbursement for an initial
residential health care facility visit and vice versa.
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 physician, group,
shared health care facility, or practitioner sharing a common
record.
If the setting is a nursing facility or hospital, the Initial
Visit concept will still apply for reimbursement purposes
despite CPT reference to the term Initial Hospital Care or
Comprehensive Nursing Facility Assessments. Subsequent
readmissions to the same facility may be reimbursed as Initial
Visits, if the readmission occurs in more than 30 days from a
previous discharge from the same facility by the same provider.
In instances when the readmission occurs within 30 or less days
from a previous discharge, the provider shall bill the relevant
HCPCS procedure codes specified in the qualifier under the
headings Subsequent Hospital Care or Subsequent Nursing Facility
Care.
Initial Hospital Visit during a single admission will be
disallowed to the same physician, group, shared health care
facility, or practitioners sharing a common record who submit a
claim for a consultation and transfer the patient to their
service.
It is also to be understood that in order to receive
reimbursement for an Initial Visit, the following minimal
documentation must be on the record regardless of the setting
where the examination was performed:
Example:

1.	Chief complaint(s);
2.	Complete history of the present illness and related
systemic review--including recordings of pertinent
negative findings;
3.	Pertinent past medical history;
4.	Pertinent family history;
5.	A full physical examination pertaining to but not limited
to the history of the present illness and includes
recording of pertinent negative findings; and
6.	Working diagnoses and treatment plan including ancillary
services and drugs ordered.
NOTE: Record and documentation of visits to patients in
residential health care facilities should be maintained in
the providers' office record.
EXCEPTIONS: HCPCS procedure codes 99201 and 99202 are
exceptions to the above requirements outlined in the
qualifier for the initial visit. For codes 99201 and
99202, the provider is expected to follow the qualifier
applied to routine visit or follow-up care visit for
reimbursement purposes.

OFFICE OR OTHER OUTPATIENT SERVICES--ESTABLISHED PATIENT; HOSPITAL INPATIENT SERVICES--SUBSEQUENT HOSPITAL CARE; NURSING FACILITY SERVICES--SUBSEQUENT NURSING FACILITY CARE; AND DOMICILIARY, REST HOME OR CUSTODIAL CARE SERVICES--ESTABLISHED PATIENT

(Excludes Preventive Health Care for patients through 20 years of age.)

99211	When reference is made in your CPT manual to Office or
99211WM	Other Outpatient Services--Established Patient; Hospital
99212	Inpatient Services--Subsequent Hospital Care; Nursing
99212WM	Facility Services--Subsequent Nursing Facility Care; and
99213	Domiciliary, Rest Home or Custodial Care Services--
99213WM	Established Patient; the intent of Medicaid is to consider
99214	this service as the Routine Visit or Follow-up Care visit.
99214WM	The setting could be office, hospital, nursing facility or
99215	residential health care facility.
99215WM	In order to document the record for reimbursement
99231	purposes, a progress note for the noted visits should
99232	include the following:

99233	1.	In an office, or residential health care facility.
99311	(a)	Purpose of visit;
99312	(b)	Pertinent history obtained;
99313	(c)	Pertinent physical findings including pertinent
99331	negative findings based on the above;
99332	(e)	Lab, X-ray, EKG, etc., ordered with results; and
99333	(f)	Diagnosis.
2.	In a hospital or nursing facility setting.
(a)	Update of symptoms;
(b)	Update of physical findings;
(c)	Resume of findings of procedures, if any done;
(d)	Pertinent positive and negative findings of lab,
X-ray;
(e)	Additional planned studies, if any, and why; and
(f)	Treatment changes, if any.

HOME SERVICES AND HOUSE CALLS

99343	House Call
99353
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 setting. These codes
refer to a physician visit limited to the provision of medical
care to an individual who would be too ill to go to a
physician's office and/or is "home bound" due to his/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	Home Visit
99341WM	For purposes of Medicaid reimbursement, these codes
99342	apply when the provider visits Medicaid recipients in the
99342WM	home setting and the visit does not meet the criteria
99351	specified House Call listed above.
99351WM
99352
99352WM

The record and documentation of a Home Visit or House Call shall become part of the office progress notes and shall include, as appropriate, the following information:

1.	Purpose of visit;
2.	Pertinent history obtained;
3.	Pertinent physical findings, including pertinent negative
physical findings based on 1. and 2.;
4.	Procedures, if any performed, with results;
5.	Lab, X-ray, ECG, etc, ordered with results; and
6.	Diagnosis(es) plus treatment plan status relative to
present or pre-existing illness(es) plus pertinent
recommendations and actions.

CONSULTATIONS

A consultation is recognized for reimbursement only when

performed by a specialist recognized as such by this Program

and the request has been made by or through the patient's

attending physician and the need for such a request would be

consistent with good medical practice. Two types of

consultation are recognized for reimbursement--comprehensive

consultation and limited consultation.

COMPREHENSIVE CONSULTATION

99244	In order to receive reimbursement for HCPCS codes
99245	99244, 99245, 99254, 99255, 99274 and 99275, the performance
99254	of a total systems evaluation by history and
99255	physical examination, including a total systems review and
99274	total system physical examination, are required. An alternative
99275	to that would be the utilization of one or more hours of
the consulting physician's personal time in the performance of
the consultation.
Reimbursement for HCPCS codes 99244, 99245, 99254, 99255, 99274
and 99275 (Comprehensive Consultation) requires the following
applicable statements, or language essentially similar to those
statements, to be inserted in the "remarks section" of the claim
form. The form is to be signed by the provider who performed the
consultation.
Examples:

1.	I personally performed a total (all) systems evaluation by
history and physical examination, or
2.	This consultation utilized 60 or more minutes of my
personal time.

The following rules regarding consultations should also be recognized:

1. If a consultation is performed in an inpatient or outpatient setting and the patient is then transferred to the consultant's service during that course of illness, then the provider may not bill for an Initial Visit if he/she bills for the consultation.

2. If there is no referring physician, then an Initial Visit code should be used instead of a consultation code.

3. If the patient is seen for the same illness on repeated visits by the same consultant, these visits are considered routine visits or follow-up care visits and not consultations.

4. Consultation codes will be declined in an office or residential health care facility setting if the consultation has been requested by or between members of the same group, shared health care facility or physicians sharing common records. A routine visit code is applicable under these circumstances.

5. If a prior claim for comprehensive consultation visit has been made within the preceding 12 months, then a repeat claim for this code will be denied if made by the same physician, physician group, shared health care facility or physicians using a common record except in those instances where the consultation required the utilization of one hour or more of the physician's personal time. Otherwise, applicable codes would be limited consultation code if their criteria are met.

LIMITED CONSULTATION

99241	The area being covered for reimbursement purposes is
99242	"limited in the sense that it requires less than the
99243	requirements designated as "comprehensive" as noted
99251	above (Comprehensive Consultation).
99252
99253
99271
99272
99273

SECOND OPINION PROGRAM CONSULTATION

99274YY	A consultation to satisfy the requirements of the mandated
"Second Opinion" program will be reimbursed only if the
requirements of that program are met and the consultation has
been performed by the appropriate Board Certified Specialist who
has signed a separate provider agreement and whose selection has
been through the Second Opinion Referral Service. The
appropriate HCPCS code is 99274YY. Reference should be made to
Appendix D of the Surgery Section (4.3) of this Subchapter for
more detail concerning the program "Second Opinion Referral
Service". Also, providers may contact the Second Opinion
Referral Service directly at the following toll free number
1-800-676-6562. An indicator "S" will be found in the "IND"
column of the HCPCS code listing in the Surgery Section to
indicate that procedure requires a Second Opinion Program
Consultation.

THIRD OPINION CONSULTATION

99274ZZ	In the event that a patient receives two different points of
view relative to a "Second Opinion" procedure, he/she may, if
unable to reach a decision, request a Third Opinion. The CPT
Procedure Code is 99274ZZ. Note: A Third Opinion consultation
must be at the patient's request and under the circumstances
described.

EMERGENCY DEPARTMENT SERVICES

A.	Physician's Use of Emergency Room Instead of Office:

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

B.	Hospital-Based Emergency Room Physicians:

99281	When patients are seen by hospital-based emergency
99282	room physicians who are eligible to bill the Medicaid program,
99283	the the appropriate HCPCS code is used. The
99284	"Visit" codes are limited to 99281, 99282, 99283, 99284
99285	and 99285.

CRITICAL CARE SERVICES

99291	Critical care will be covered under the code 99291 and
99292	99292, but the service must be consistent with the following
narrative in order to be reimbursed. The patient's situation
requires constant physician attendance which is given by the
physician to the exclusion of his/her other patients and duties
and, therefore, for him/her, represents what is beyond the usual
service. This must be verified by the applicable records as
defined by the setting and which records must show in the
physician's handwriting the time of onset and time of completion
of the service. All settings are applicable such as office,
hospital, home, residential health care facility and nursing
facility.
NOTE: These codes may not be used simultaneously with procedure
codes that pay a reimbursement for the same time or type of
service.

PREVENTIVE MEDICINE SERVICES--ANNUAL HEALTH MAINTENANCE EXAMINATION
New Patient	Established Patient
99382	99392
99383	99393
99384	99394
99385	99395
99386	99396
99387	99397

For individuals under 21 years of age, the following must be performed and documented in the recipient's record:

1. History (complete initial for new patient, interval for established patient) including past medical history, family history, social history, and systemic review.

2. Developmental and nutritional assessment.

3. Complete, unclothed, physical examination to include also the following:

(a) measurements: height and weight; head circumference to 25 months; blood pressure for children age 3 or older.

(b) vision and hearing screening.

4. Assessment and administration of immunizations appropriate for age and need.

5. Provisions for further diagnosis, treatment and follow-up, by referral if necessary, of all correctable abnormalities uncovered or suspected.

6. Referral to a dentist for children age 3 or older.

7. Laboratory procedures performed or referred if medically necessary. Recommendations are:

(a) Hemoglobin/Hematocrit three times: 6-8 months; 2-3 or 4-6 years; and 10-12 years.

(b) Urinalysis a minimum of twice: 18-24 months and 13-15 years.

(c) Tuberculin test (Mantoux): 9-12 months; and annually thereafter.

(d) Lead screening using blood lead level determinations between 6 and 12 months, at 2 years of age, and annually up to 6 years of age. At all other visits, screening shall consist of verbal risk assessment and blood lead level test, as indicated.

(e) Other appropriate screening procedures, if medically necessary (for example: blood cholesterol, test for ova and parasites, STD).

8. Health education and anticipatory guidance.

9. Offer of social service assistance; and, if requested, referral to County Welfare Agency.

10. Referral for further diagnosis and treatment or follow-up of all correctable abnormalities, uncovered or suspected. Referral may be made to the provider conducting the screening examination or to another provider, as appropriate.

11. Referral to the Special Supplemental Food program for Women's Infants and Children (WIC) is required for children under 5 years of age and for pregnant or lactating women.

Note: Preventive medicine services codes (new patient) 99382, 99383, 99384, 99385, 99386, and 99387 are comparable to an initial visit and, therefore, may only be billed once. Future use of these codes will be denied when the recipient is seen by the same physician, group of physicians, or involves a shared health care facility, group of physicians sharing a common record. These codes will also be automatically denied for payment when used following an EPSDT examination (procedure code W9820) performed within the preceding 12 months.

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.

Preventive medicine services code 99391 and 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. These codes do not apply to children under 2 years of age participating in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) or Pediatric HealthStart program. EPSDT and the Pediatric HealthStart providers bill for these services using the program appropriate codes W9060-W9068 or W9060WT-W9068WT.

NEWBORN CARE

ROUTINE HOSPITAL NEWBORN CARE--"WELL" BABY

99431	Routine Hospital Newborn Care. For reimbursement purposes, code
99431 requires as a minimum routine newborn care by a physician
other than the physician(s) 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. This applies to
health newborns. Consequently, the provider is not permitted to
bill subsequent day or discharge day for a healthy newborn.

NEWBORN CARE--"SICK" BABY

For sick babies use appropriate hospital care code:

99221	1.	Initial hospital care-99221, 99222 or 99223.
99222
99223
99231	2.	Subsequent hospital care-99231, 99232 or 99233.
99232
99233
99291	3.	Critical care services if applicable-99291 or 99292.
99292

(f) The following statements apply to HCPCS procedure codes which require medical justification.

1. The following is a list of the procedure codes for certain surgical and diagnostic procedures which are reimbursable only when acceptable written justification by the physician accompanies the claim form. The medical justification must include an explanation of the medical justification of the procedure, as appropriate and in accordance with established clinical protocols, and appropriate licensing statute and regulations by the appropriate Board.

2. The medical necessity may be stated in the "REMARKS" box 34 of the 1500 N.J. claim form. If Box 34 does not provide sufficient space, an addendum may be attached to the claim form. (See also 10:54-3.2 for regulations regarding this program.) The indicator "M" precedes the procedure codes which require medical justification.

3. LIST OF HCPCS PROCEDURE CODES REQUIRING MEDICAL JUSTIFICATION

64804	71020
64804 50	71030
64818	71034
64818 50	74710
71010	75710

(g) Cosmetic surgery: The following are a list of procedure codes that are considered by Medicaid as cosmetic surgical procedures and unless prior authorized as a result of being considered medically necessary, are not reimbursed.

15780	15819	19318	30400	69300
15781	15820	19318 50	30410	69300 50
15782	15821	19324	30420

New Patient	Established Patient
15783	15822	19325 50	30430
15786	15823	19325	30435
15787	15824	30450
15788	15826	21120	30460
15789	15831	through	30462
15792	21198	30520
15793

(h) Physician Administered Drugs

1. The New Jersey Division of Medical Assistance and Health Services provides physician reimbursement for the administration of medications. Reimbursement will continue to be available for the administration of the drug. The procedure code 90799 may be billed for intradermal, subcutaneous, intramuscular, or intravenous drug administration.

2. However, reimbursement for the drug administered by a physician, other than immunizations, was only available if a prescription was issued and the drug was obtained from a pharmacy which directly billed the New Jersey Medicaid program.

3. Unless otherwise indicated, the Medicaid maximum fee allowance shall be based on the AWP per unit which equals one cubic centimeter (CC) or milliliter (ml). For drug vials with a volume equal to one cc or ml, the Medicaid maximum fee allowance shall be based on the cost per vial. For further information on physician administered drugs, see N.J.A.C. 10:54-8.6.

HCPCS

Maximum Fee

Code	Description	Allowance
J0690	Cefazolin 500 mg	$ 1.92
J0696	Ceftriaxone 250 mg	10.24
J1100	Dexamethasone 4 mg	0.80
J1200	Diphenhydramine 50 mg	0.55
J2550	Promethazine 50 mg	0.42
J2680	Fluphenazine Decanoate 25 mg	9.50
J2790	RhoGAM, Rho (D) Immune Globulin (Human) Single	20.40
dose (Micro-Dose)
J2790 22	RhoGAM, Rho (D) Immune Globulin (Human) Single	72.07
dose (Full dose) (22--Services greater than usual)
J9000	Doxorubicin 10 mg	42.00
J9010	Doxorubicin 50 mg	195.50
J9020	Asparaginase 10,000 Units	50.36
J9031	BCG Live Vaccine 27 mg	152.13
J9040	Bleomycin Sulfate 15 units	255.08
J9045	Carboplatin 50 mg	72.01
J9060	Cisplatin Powder or Solution 10 mg	30.33
J9070	Cyclophosphamide 100 mg	4.91
J9100	Cytarabine 100 mg	6.72
J9130	Decarbazine 100 mg	12.00
J9190	Fluorouracil 50 mg	0.18
J9217	Lupron 7.5 mg	451.25
J9230	Mechlorethamine HC1 10 mg	10.10
J9240	Medroxyprogesterone 100 mg	9.05
J9240 22	Medroxyprogesterone 400 mg	31.50
J9260	Methotrexate Sodium 50 mg	4.75
J9280	Mitomycin 5 mg	119.08
J9360	Vinblastine Sulfate 1 mg	3.25
J9370	Vincristine 1 mg	27.50
W9095	Immunization--Tetanus antitoxin	6.60

(i) Hepatitis B Vaccine: Coverage is available for post exposure prophylaxis and for vaccination of individuals in selected high risk groups, regardless of age, in accordance with the criteria defined by the CDC. In all such cases, the need for this vaccination must be fully documented in the recipient's medical record. In order to facilitate reimbursement for Hepatitis B immunoprophylaxis for high risk individuals, manufacturer, age, and dose specific procedure codes have been developed for use by physicians and independent clinics providing this service.

EXCEPTION: The New Jersey Medicaid program will reimburse for the universal vaccination of infants born on and after January 1, 1992, whose immunization was delayed beyond the newborn period because this policy was not yet in effect. However, the immunization schedule must be completed before the infant's second birthday.

W9096	Hepatitis B immunoprophylaxis with Recombivax	17.46
HB, 0.25 ml dose. This code applies only to
newborns of HBsAg negative mothers.
W9096 22	Hepatitis B immunoprophylaxis with Recombivax	32.79
HB, 0.5 ml dose. This code applies only to
newborns of HBsAg positive mothers.
W9097	Hepatitis B immunoprophylaxis with Recombivax	17.46
HB, 0.25 ml dose. This code applies only to
high risk recipients under 11 years of age
(exclusive of newborns).
W9098	Hepatitis B immunoprophylaxis with Recombivax	32.79
HB, 0.5 ml dose. This code applies only to high
risk recipients 11-19 years of age.
W9099	Hepatitis B immunoprophylaxis with Recombivax	63.57
HB, 1.0 ml dose. This code applies only to high
risk recipients over 19 years of age.
W9333	Hepatitis B immunoprophylaxis with Engerix-B,	27.88
0.5 ml dose. This code applies only when
immunizing newborns.
W9334	Hepatitis B immunoprophylaxis with Engerix-B,	27.88
0.5 ml dose. This code applies only to high
risk recipients under 11 years of age
(exclusive of newborns)
W9335	Hepatitis B immunoprophylaxis with Engerix-B,	62.09
1.0 ml dose. This code applies only to high
risk recipients over 11 years of age.
W9336	Medroxyprogesterone Acetate 150 mg	36.90
W9337	Cephradine 250 mg	2.34
W9338	TETRAMUNE, a biological combining Diphtheria,	30.27
Tetanus Toxoids and Pertussis Vaccine (DTP)
with Hemophilus B Conjugate Vaccine
QUALIFIER: Not to be billed separately with
HCPCS 90701 or 90731.
W9339	Lupron 3.75 mg	360.63
W9343	Lupron Depot Pediatric 7.5 mg	451.25
W9344	Lupron Depot Pediatric 11.25 mg	811.25
W9345	Lupron Depot Pediatric 15 mg	902.50

N.J. Admin. Code § 10:54-9.8

Amended by 48 N.J.R. 962(b), effective 6/6/2016