N.J. Admin. Code § 10:52-10.1

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:52-10.1 - Introduction

(a) The New Jersey Medicaid/FamilyCare fee-for-service program utilizes the Centers for Medicare & Medicaid Services' (CMS's) Healthcare Common Procedure Coding System (HCPCS) for 2009, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191, and incorporated herein by reference, as amended and supplemented, and as published by PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010. Revisions to the Healthcare Common Procedure Coding System made by CMS (code additions, code deletions and replacement codes) will be reflected in this subchapter through publication of a notice of administrative change in the New Jersey Register. Revisions to existing reimbursement amounts specified by the Department and specification of new reimbursement amounts for new codes will be made by rulemaking in accordance with the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. HCPCS follows the American Medical Association's Physicians' 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.

1. LEVEL I CODES (Narratives found in CPT)

These codes are adapted from CPT for utilization primarily by Physicians, Podiatrists, Optometrists, Certified Nurse Midwives, Certified Nurse Practitioners, Independent Clinics and Independent Laboratories. CPT is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians.

Copyright restrictions make it impossible to print excerpts from CPT procedure narratives for Level I codes. Thus, in order to determine those narratives it is necessary to refer to CPT, which is incorporated herein by reference, as amended and supplemented. An updated copy of the CPT (Level I) codes may be obtained from the American Medical Association, P.O. Box 10950, Chicago, IL 60610, or by accessing www.ama-assn.org.

2. LEVEL II CODES (Narratives found at N.J.A.C. 10:52-10.3)

These codes are assigned by CMS for physicians and non-physician services which are not in CPT. An updated copy of the HCPCS (Level II) codes may be obtained by accessing the HCPCS website at www.cms.gov/TransactionCodeSetsStands/or by contacting PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010.

(b) The responsibility of the provider when rendering specific services and requesting reimbursement is listed in both Subchapter 1 and Subchapter 2 of N.J.A.C. 10:52, Hospital Services.

(c) Regarding specific elements of HCPCS codes which requires attention of the provider, the lists of HCPCS code numbers for Pathology and Laboratory are arranged in tabular form with specific information for a code identified under columns with titles such as: "IND," "HCPCS CODE," "MOD," "DESCRIPTION," and "MAXIMUM FEE ALLOWANCE." The information identified under each column is summarized below:

1 A
Column Title	Description
IND	(Indicator Qualifier) Lists alphabetic symbols used
to refer provider to information concerning the New
Jersey Medicaid/NJ FamilyCare fee-for-service
program's qualifications and requirements when a
procedure or service code is used. Explanation of
indicators and qualifiers used in this column are
identified below:
"A" preceding any procedure code indicates that these
tests can be and are frequently done as groups and
combinations (profiles) on automated equipment.
"F" preceding any procedure code indicates that this
code, when used primarily for the diagnosis and
treatment of infertility, is not covered by the New
Jersey Medicaid/NJ FamilyCare program.
"L" preceding any procedure code indicates that the
complete narrative for the code is located at N.J.A.C.
10:52-10.3.
"N" preceding any procedure code indicates that
qualifiers are applicable to that code. These
qualifiers are listed by procedure code number at N.J.
A.C. 10:52-10.4.
HCPCS CODE	Lists the HCPCS procedure code numbers.
MOD	Lists alphabetic and numeric symbols. Services and
procedures may be modified under certain circumstances.
When applicable, the modifying circumstance has been
identified by the addition of alphabetic and/or
numeric characters at the end of the code. The New
Jersey Medicaid/NJ FamilyCare program's recognized
modifier codes are listed at N.J.A.C. 10:52-10.5.
DESCRIPTION	Lists the code narrative. (Narratives for Level I
codes are found in the CPT. Narratives for Level II
codes are found at N.J.A.C. 10:52-10.3.)
MAXIMUM FEE	Lists the New Jersey Medicaid/NJ FamilyCare
ALLOWANCE	fee-for-service program's maximum reimbursement
schedule for Pathology and Laboratory services. If the
symbols "S.C.C." (Subject Cost-to-Charge) are listed
instead of a dollar amount, it means that service is
subject to the cost-to-charge ratio. If the symbols "N.
A." (Not Applicable) are listed instead of a dollar
amount, it means that service is not reimbursable.

1. The fee listed under "Office Total Fee(s)" represents the combined technical and professional component of the reimbursement for the procedure code notwithstanding any statement to the contrary in the narrative. It will be paid only to one provider and will not be broken down into its component parts.

2. The fee schedule for all diagnostic Medical, Radiology and Pathology services performed in a hospital setting is indicated in the "Prof. Comp" and represents the professional component for those hospital based physicians whose contract is based on fee-for-service.

(d) Regarding alphabetic and numeric symbols under "IND" and "MOD", these symbols when listed under the "IND" and "MOD" columns are elements of the HCPCS coding system used as qualifiers or indicators (as in the "IND" column) and as modifiers (as in the "MOD" column). They assist the physician in determining the appropriate procedure codes to be used, the area to be covered, the minimum requirements needed, and any additional parameters required for reimbursement purposes.

1. These symbols and/or letters must not be ignored because in certain instances requirements are created in addition to the narrative which accompanies the CPT/HCPCS procedure code as written in CPT-4. The provider will then be liable for the additional requirements and not just the CPT/HCPCS procedure code narrative. These requirements must be fulfilled in order to receive reimbursement.

2. If there is no identifying symbol listed, the CPT/HCPCS code narrative prevails.

N.J. Admin. Code § 10:52-10.1

Amended by 50 N.J.R. 1261(a), effective 5/21/2018