N.J. Admin. Code § 10:54-5.40

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

Section 10:54-5.40 - Second opinion program for elective surgical procedures-hospital inpatient and ambulatory surgical centers (ASC) services

(a) A second opinion shall be required for the elective surgical procedures listed under (b) below. The outcome of the second opinion will have no bearing on payment. Once the second opinion is rendered, the patient will retain the right to decide whether or not to proceed with the surgery; however, failure to obtain a second opinion for these procedures will result in a denial of the surgeon's claim. (See 10:54-9.11(c) and (d) for the list of HCPCS codes that require a second opinion.)

1. A second opinion shall be required for the surgery indicated below when the surgical procedure is elective. If the operating physician determines that the need for surgery is urgent or is an emergency, no opinion is required. Urgent or emergency (for second opinion purposes) includes any situation in which a delay in performing surgery in order to meet the second opinion requirement could result in a significant threat to the patient's health or life.

i. If the patient is hospitalized or admitted to an ASC, a second opinion is not required if the procedure becomes urgent or an emergency during the course of the hospitalization or admission, regardless of the patient's admitting diagnosis.

ii. Reimbursement for urgent or emergency surgery shall be made only if a specific statement is attached to the claim form by the operating physician certifying that the second opinion requirement was not met and substantiating the urgent or emergency nature of the surgery.

2. A second opinion shall be required for any of the elective procedures whenever the New Jersey Medicaid/NJ FamilyCare program is to be billed for any portion of the physician claim. Therefore, if a Medicaid patient is covered by other insurance (except when Medicare coverage is involved) which makes only partial payment on the claim, the New Jersey Medicaid/NJ FamilyCare program shall not make supplementary payment unless the second opinion requirement has been met. However, the New Jersey Medicaid/NJ FamilyCare program shall make payment on the claim if the operating physician receives documentation that a second opinion was arranged and paid by another insurer. A copy of this documentation must be attached to the claim.

3. A second opinion shall be required for any of the four procedures to be done on an elective basis, even if the recommendation for surgery is made during the inpatient hospital stay or ASC admission. In this case, the patient should be discharged and the regular process for obtaining a second opinion should be followed. If the patient decides to have surgery, he or she can then be scheduled for readmission since the case would have been elective in nature.

(b) The following elective surgical procedures require a second opinion by a physician under the Medicaid Second Opinion program:

1. Hernia Repair (common abdominal wall type);

i. A second opinion shall be required for any herniorrhaphy involving an adult (over 18 years of age).

ii. A second opinion shall not be required for herniorrhaphy involving a child or young adult 18 years of age or under.

2. Hysterectomy (see also 10:54-5.16(h) through (k) );

3. Laminectomy;

4. Spinal fusion;

i. A second opinion shall not be required for spinal fusion for scoliosis in a child or young adult 18 years of age or under.

(c) The Medicaid Second Opinion program shall not require a second opinion for the following circumstances:

1. New Jersey Medicaid beneficiaries with HSP (Medicaid) Case Numbers with the first and second digits of 90 or the third and fourth digits of 60 who are residing out-of-State at the discretion of the New Jersey Department of Human Services.

2. Dually eligible Medicare/Medicaid beneficiaries, unless a second opinion is also mandatory under Medicare regulations.

(d) Medicare/Medicaid beneficiaries may optionally, (that is, on a voluntary basis) seek "second opinions" and the cost of the service shall be reimbursed by the New Jersey Medicaid program if not covered for reimbursement by Medicare.

(e) A second opinion shall be arranged through the fiscal agent's Medicaid Second Opinion Referral Center.

1. A consultation ordered by a physician shall not, by itself, meet the program's definition of a second opinion and no "Authorization for Payment" shall be granted based on such consultation. Second opinions arranged and paid for by other third party payers, in accordance with (a)2 above, will be considered second opinions by Medicaid.

2. All second opinion providers shall be Board Certified or Board Eligible by the appropriate American specialty board or osteopathic specialty board. The Referral Center shall ensure that the second opinion physician is a Board Certified or Board Eligible Specialist in the appropriate field (General Surgery, Pediatrics, Neurology, Neurosurgery, Obstetrics/Gynecology, or Orthopedics), and has signed a Medicaid Second Opinion Provider Agreement.

i. To become approved as a Medicaid Second Opinion provider and receive a Second Opinion Provider Agreement application, contact the Medicaid Second Opinion Referral Center at the fiscal agent of the New Jersey Medicaid program.

3. The physician shall agree when completing the Second Opinion Provider Agreement not to perform surgery on the individual to whom he has given a second opinion, and not to make a referral unless requested by the patient, and then only to a surgeon with whom the second opinion has no financial involvement.

4. A second opinion shall be required, regardless of the setting in which the procedure is to be performed (inpatient hospital, outpatient hospital, independent clinic, Ambulatory Surgical Center, or physician's office).

5. In order to prevent claim denial as a result of a situation where one of the elective surgical procedures is scheduled and performed before the second opinion requirements are met, it is suggested that the elective surgery not be scheduled until after the second opinion has been rendered.

(f) At the time a recommendation for surgery is made, the first opinion physician or the patient's operating surgeon will give the patient a bilingual Medicaid Second Opinion program brochure which explains the program and the steps for obtaining a second opinion. The physician should check the appropriate box on the brochure to indicate the procedure being recommended. Copies of the brochure are available from the fiscal agent of the New Jersey Medicaid program.

1. The patient shall then follow the instructions outlined in the brochure to contact the Medicaid Second Opinion Referral Center and obtain a second opinion.

2. At the time the second opinion is rendered, the second opinion physician may contact the first opinion physician or the patient's operating surgeon to discuss the patient's medical history and the result of the previous diagnostic studies.

3. The second opinion physician will document the results of the second opinion on the Medicaid Second Opinion Referral Form. A copy of this report shall be forwarded by the Medicaid Second Opinion Referral Center to the referring physician.

4. If the patient wishes to proceed with surgery after a second opinion is received, the operating physician shall contact the Referral Center to receive an "Authorization for Payment" prior to proceeding with the surgery.

i. A copy of the Second Opinion Report, as well as authorization for physician payment will then be sent to the operating physician. At the time the patient's hospital, independent clinic, or ambulatory surgical center (ASC) admission is arranged, the operating physician shall give the hospital or independent clinic or ASC its copy of the "Authorization for Payment". The second opinion is valid for one year from the date the second opinion is rendered.

(g) The physician claim associated with one of the second opinion procedures shall not be paid unless attached to the hard copy of the claim is:

1. An "Authorization for Payment", or

2. Documentation of a second opinion arranged through another insurer; or

3. A specific statement from the operating physician certifying that the second opinion requirement was not met and substantiating the urgent or emergency nature of the surgery.

(h) Reimbursement will not be made for a second opinion rendered to a patient who is not Medicaid eligible. The issuance of a "Medicaid Second Opinion Referral Form" to the patient by the Medicaid Second Opinion Referral Center does not guarantee the patient's eligibility on the date of the second opinion or subsequent surgery. The patient's eligibility must be verified by checking the patient's current New Jersey Medicaid Validation Form before rendering any service. (See 10:49-1.2, Administration on "How to identify a Medicaid beneficiary."

(i) Third opinion: If as a result of the second opinion, the patient is given a conflicting opinion regarding the need for the elective surgery, the patient may contact the Medicaid Second Opinion Referral Center and arrange for a third opinion. (For third opinion billing, see 10:54-9.4 under procedure code 99274 ZZ.)

(j) For physician claim submission, the operating surgeon, upon receipt of the Second Opinion "Authorization of Payment" shall go through the normal process for arranging the surgery, ensuring the hospital, independent clinic or ASC receives its copy of the authorization.

1. If the patient should change physicians after the authorization has been released, the newly designated operating physician may contact the Medicaid Referral Center for a copy.

2. Once the surgery is performed, the physician must attach to the Physician's claim form (CMS 1500) either the operating physician's copy of the "Authorization of Payment" or a statement certifying as to the urgent or emergency nature of the procedure.

3. No Second Opinion authorization or certification shall be required for the anesthesiologist or assistant surgeon claims.

N.J. Admin. Code § 10:54-5.40

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (c)1, (c)2, (d) and (h), substituted "beneficiaries" for "recipients" throughout; in (h), substituted "beneficiary" for "recipient" preceding "identify a Medicaid".
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)2, inserted "/NJ FamilyCare" three times; in the introductory paragraph of (j), deleted a comma following "clinic"; and in (j)2, substituted "CMS" for "HCFA".