Statutes, codes, and regulations
New Jersey Administrative Code
Title 10 - HUMAN SERVICESChapter 52 - HOSPITAL SERVICES MANUAL
Subchapter 10 - CENTERS FOR MEDICARE & MEDICAID SERVICES HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) FOR HOSPITAL OUTPATIENT LABORATORY SERVICES
Section 10:52-10.4 - Pathology and Laboratory HCPCS Codes-Qualifiers

N.J. Admin. Code § 10:52-10.4

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Current through Register Vol. 57, No. 1, January 6, 2025
Section 10:52-10.4 - Pathology and Laboratory HCPCS Codes-Qualifiers
(a) Qualifiers for pathology and laboratory services are summarized below:
1. Organ or Disease Oriented Laboratory Panels

NOTE: The following calculations and ratios are not eligible for separate or additional reimbursement.

A/G RatioGlobulin
BUN/Creatinine RatioFTI (T7)
Free CalciumFree Thyroxine

2. Codes 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, and 80076. The panels listed must include the laboratory tests assigned by the CPT as the components of the panel. The tests listed with each of the panels identify the defined components of that panel. If any laboratory tests included in the panel are billed a la carte, the tests must be billed as the panel. The laboratory provider may not charge Medicaid/NJ

FamilyCare fee-for-service program more than the lowest charge level offered to another provider. The lowest charges for the laboratory test comprising the panel must aggregate as equivalent to or greater than the listed panel fee.

3. Codes 82487, 82488, and 82489--Chromatography--must list substance (compound) tested for in block 34 (REMARKS) of the claim form.
4. Code 84202--Protoporphyrin, RBC; quantitative--Utilize only for testing of anemia. Utilize code 84203--Protoporphyrin, RBC; screen when testing for anemia. Code 84203 will no longer be reimbursed when billed in conjunction with code 83655--Blood lead determination (quantitative).
5. Code 84620--Xylose absorption tests, blood and/or urine (D-xylose tolerance test), includes serum & urine levels, up to 5 hourly specimens.
6. Codes 85025 and 85027--Hematology

NOTE: For purpose of reimbursement based on this schedule, a complete blood count (CBC) includes a hematocrit, hemoglobin determination, RBC count, RBC indices, WBC count and differential WBC count.

Hematology codes 85014, 85018, 85041 and 85048 may not be reimbursed in conjunction with codes for blood count with hemogram (85025, and 85027).

The code for manual differential WBC count (85007) may not be reimbursed in conjunction with codes 85025, and 85027.

Codes for platelet count 85049 may not be reimbursed in conjunction with codes 85025 and 85027.

7. Codes 87040, 87045, 87070, 87184--Cultures

NOTE: These codes may only be reimbursed when a pathogenic microorganism is reported. A culture that indicates no growth or normal flora must be billed as a presumptive culture; (87081).

8. Code 88155--Pap smear

NOTE: Obtaining specimen not a separate eligible service.

9. Code 88348 and 88349--Electron microscopy; diagnostic and scanning are not reimbursable when used as a research tool.

NOTE: For reimbursement purposes, the Medicaid/NJ FamilyCare fee-for-service programs will pay for the above diagnostic scanning procedure when it pertains to x-ray microanalysis for identification of asbestos particles and heavy metals, that is, gold, mercury, etc. and also when examining tissue specimens in occasional cases of malabsorption.

10. Code 36415--Utilize this code only for finger/heel/ear stick for collection of specimen(s). This service is reimbursable in the physician office laboratory (POL) when the specimen is referred out to an independent clinical laboratory for testing. Finger/heel/ear stick is not reimbursable when billed by the independent clinical laboratory.

N.J. Admin. Code § 10:52-10.4

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