N.J. Admin. Code § 10:54-4.12

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:54-4.12 - Physician reimbursement in special situations

(a) A hospital-based physician who is salaried and whose services are reimbursed as part of the hospital's cost shall not bill fee-for-service to the New Jersey Medicaid/NJ FamilyCare program.

(b) A physician practicing in a hospital outpatient department whose reimbursement is not part of the hospital's cost may bill fee-for-service to the New Jersey Medicaid/NJ FamilyCare program, independent of the hospital charges for professional services, if the physician's arrangement with the hospital permits it.

(c) If a patient receives care from more than one member of a partnership or corporation in the same discipline, the maximum fee allowance shall be the same as that for a single attending physician.

(d) Reimbursement shall not be made for, and beneficiaries shall not be asked to pay for, broken appointments.

(e) Reimbursement shall be made for injections (intradermal, subcutaneous, intramuscular, intravenous) which are administered by the physician according to N.J.A.C. 10:54-9.4 and N.J.A.C. 10:54-9.8.

1. Reimbursement for immunization services will be based on the formula of Average Wholesale Price (AWP) of the drug plus 15 percent, plus $ 2.00 for physician's cost of dispensing the immunization. For specific qualifiers for immunizations, see N.J.A.C. 10:54-9.8(a) and (i) and N.J.A.C. 10:54-9.10(f).

(f) Reimbursement for psychiatric consultation or shock therapy shall be considered as inclusive of all psychiatric services that day.

(g) Reimbursement for Early and Periodic Screening, Diagnosis and Treatment shall be made in accordance with N.J.A.C. 10:54-5.5, N.J.A.C. 10:54-9.4 and 9.10(l)4.

(h) Reimbursement for HealthStart services shall be made in accordance with N.J.A.C. 10:54-6 and N.J.A.C. 10:54-9.10(k).

N.J. Admin. Code § 10:54-4.12

Recodified from N.J.A.C. 10:54-4.11 by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Former N.J.A.C. 10:54-4.12, HCPCS codes for surgical procedures; general, recodified to N.J.A.C. 10:54-4.13.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (d), substituted "beneficiaries" for "recipients" preceding "shall not be asked".
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In (a) and (b), inserted "/NJ FamilyCare".