N.J. Admin. Code § 10:62-1.13

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

Section 10:62-1.13 - Consultations

(a) A consultation shall be eligible for reimbursement only when the consultation has been performed by a specialist recognized as such by the Medicaid/NJ FamilyCare programs, 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 shall be eligible for reimbursement: comprehensive consultation and limited consultation.

(b) In order to receive reimbursement for the HCPCS for an office consultation (99244, 99245) or a confirmatory consultation (99274 and 99275), the provider shall perform a total systems evaluation by history and physical examination, including a total systems review and total systems physical examination, or, alternatively, utilize one or more hours of the consulting physician's personal time in the performance of the consultation.

(c) In addition to the recordkeeping requirements of N.J.A.C. 10:62-1.21, reimbursement for HCPCS 99244, 99245, 99274, and 99275, related to the provision of a comprehensive consultation, requires that the applicable statements listed below, or language essentially similar to those statements, be inserted in the "remarks" section of the claim form. The claim form shall be signed by the provider who performed the consultation.

1. Examples:

i. I personally performed a total (all) systems evaluation by history and physical examination; or

ii. This consultation utilized 60 or more minutes of my personal time.

(d) The following regarding consultations shall also apply:

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, the provider shall not bill for an Initial Visit in addition to billing for the consultation.

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

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

4. Consultation HCPCSs shall be denied 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 a comprehensive consultation visit has been made within the preceding 12 months, then a repeat claim for this code shall 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 codes if their criteria are met.

(e) For reimbursement purposes, HCPCS 99241, 99242, 99243, 99251, 99252, 99253, 99271, 99272, and 99273 are considered "limited" because the consultation requires less than the requirements designated as "comprehensive" as noted in (c) above.

(f) When multiple special ophthalmological services or ophthalmoscopic services are billed on the same day for the same patient in an office setting, reimbursement shall be limited to the highest valued procedure.

N.J. Admin. Code § 10:62-1.13

Amended by 49 N.J.R. 2279(b), effective 7/17/2017