N.J. Admin. Code § 10:54-5.5

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:54-5.5 - Diagnostic endoscopic procedure; without biopsies

(a) For diagnostic endoscopic procedures which do not involve biopsy(ies), if an endoscopic procedure is performed as a single procedure, the maximum reimbursement shall be 100 percent of the HCPCS code.

(b) Reimbursement shall be made for either the endoscopic procedure or the office or outpatient visit, but not for both.

(c) Nasal endoscopy (HCPCS 31231-31235) without the 22 modifier (without biopsy) shall not be reimbursed in combination with other diagnostic endoscopies involving the respiratory system performed by the same physician at the same session.

(d) If two or more diagnostic endoscopic procedures are performed by the same physician during a single session and each procedure involves a different body system (as outlined in the CPT-4 classification system) each endoscopic procedure may be billed and may be reimbursed at 100 percent of the Medicaid/NJ FamilyCare Maximum Fee Allowance.

(e) Except as specified in (f) below, if two or more diagnostic endoscopic procedures involving the same body system (as outlined in the CPT classification system) are performed by the same physician during a single session, the physician shall claim and may be reimbursed for the endoscopic procedure involving only the "deepest penetration." (Often, but not always, the higher HCPCS code number in the CPT corresponds to the endoscopic procedure that has the "deeper penetration.") In this situation, only this one endoscopic procedure shall be reimbursed.

(f) When certain multiple (two or more) endoscopic procedures are defined as complex and/or involve another, different anatomical site necessitating the use of a different scope and the initiation of an independent procedure, the physician shall request reimbursement for each procedure separately at 100 percent of the Medicaid/NJ FamilyCare Maximum Fee Allowance. (See 10:54-9.4 on HCPCS for a list of these procedures.)

N.J. Admin. Code § 10:54-5.5

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (e), substituted "CPT" for "CPT-4" throughout.
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In (d) and (f), inserted "/NJ FamilyCare"; and in (d), deleted "Allowable" preceding "Fee" and inserted "Allowance".