N.J. Admin. Code § 10:54-4.26

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

Section 10:54-4.26 - Consultation services; general

(a) A consultation shall include a personal examination of the patient with a written report of the history, physical findings, diagnosis, and recommendations of the consultant for future management.

(b) When a consultation is requested from an approved State agency, a letter of agreement between the appropriate State agency and the New Jersey Medicaid/NJ FamilyCare program shall be made and the request shall be consistent with good medical practice. If there is a referral by a State agency with an appropriate contract with the New Jersey Medicaid/NJ FamilyCare program, the report shall be sent to the appropriate State agency and payment for a consultation may be reimbursed.

(c) If the consultation is performed in an emergency room setting and the patient is admitted within 24 hours to the consultant's service as an inpatient, either a consultation or initial visit may be billed. The Medicaid/NJ FamilyCare program will reimburse for only one, as appropriate. Continuing visits by the physician who has assumed the care of the patient shall be billed as subsequent hospital visits.

(d) If the patient is seen by another physician and admitted/transferred to that other physician's service, then the initial physician may continue to follow the patient and shall be reimbursed by the Medicaid/NJ FamilyCare program for concurrent care, if concurrent care can be justified as medically necessary. When a consultant assumes the continuing care of the patient, any subsequent services provided by him or her shall no longer be considered consultation, and these visits shall be billed as routine or follow-up visits. (See 10:54-4.7 for regulations on concurrent care.)

N.J. Admin. Code § 10:54-4.26

Recodified from N.J.A.C. 10:54-4.25 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. 10:54-4.26, Consultation; limited, recodified to N.J.A.C. 10:54-4.27.
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.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In (b), (c) and (d), inserted "/NJ Family Care" throughout; and in (b), substituted the first and second occurrence of "State" for "state".