N.J. Admin. Code § 10:54-9.2

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

Section 10:54-9.2 - Elements of HCPCS procedure codes which require attention

(a) The lists of HCPCS procedure code for use of physicians and other practitioners are arranged in tabular form with specific information for a code given under columns with titles such as "IND", "HCPCS CODES", "MOD", "DESCRIPTION", "FOLLOW-UP DAYS", "MAXIMUM FEE ALLOWANCE" and "ANES BASIC UNITS". The information given under each column is summarized below:

Column	Title
"IND"	(Indicator-Qualifier) Lists alphabetic symbols used to refer
provider to information concerning the New Jersey Medicaid
program's qualifications and requirements when a HCPCS procedure
code is used. Explanation of indicators and qualifiers used in
this column are given below:
"A"	preceding any procedure code indicates that these tests can be
and are frequently done as groups and combinations (profiles) on
automated equipment.
"C"	preceding any procedure code indicates that cosmetic surgery is
not payable by Medicaid unless prior authorization is received by
the provider. (See also 10:54-5.3 and 9.8(g).)
"E"	preceding any procedure code indicates that these procedures are
excluded from multiple surgery pricing and, as such, should be
reimbursed at 100 percent of the Medicaid maximum fee allowance
even if the procedure is done on the same patient by the same
surgeon at the same operative session. (See 10:54-9.11(f).)
"F"	preceding any procedure code indicates that this code, when used
primarily for the diagnosis and treatment of infertility, is not
covered by the New Jersey Medicaid program.
"I"	preceding any procedure code indicates that certain surgical
procedures when performed incidental to other surgical procedures
by the operating surgeon or assistant are covered in the
reimbursement allowance for the primary procedure.
(See 10:54-9.11(b).)
"L"	preceding any procedure code indicates that the complete narrative
for the code is located in 10:54-9.9 of this chapter.
"M"	preceding any procedure code indicates that this service is
medically necessary under the Medical Justification Program.
(See 10:54-3.1 and 9.8(f).)
"N"	preceding any procedure code means that qualifiers are applicable
to that code. (See 10:54-9.8 for qualifiers.)
"S"	preceding any procedure code indicates that a second opinion by
another physician is required for this procedure.
(See 10:54-9.11(d).)
"HCPCS CODES"--Lists the HCPCS procedure code numbers.
"MOD"	Lists alphabetic and numeric symbols. Services and procedures may
be modified under certain circumstances. When applicable, the
modifying circumstance should be identified by the addition of
alphabetic and/or numeric characters affixed to the procedure code.
The New Jersey Medicaid/NJ FamilyCare program's recognized modifier
codes are listed in 10:54-9.3.
"DESCRIPTION" -- Lists the code narrative for Level II and III procedure
codes. Narratives for Level I are in the CPT.
"FOLLOW-UP DAYS" -- Lists the number of days for follow-up care.
"MAXIMUM FEE ALLOWANCE" -- Lists New Jersey Medicaid/NJ FamilyCare program's
maximum fee allowance schedule. If the symbol "B.R." (By Report) is
listed instead of a dollar amount, it means that additional
information will be required in order to properly evaluate the
service. Attach a copy of the report to the claim form. If the
symbol "N.A." (Not Applicable) is listed instead of a dollar amount,
it means that service is not reimbursable.
"ANES BASIC UNITS" --B.U.V. (Basic Unit Value) + A.T. (Anesthesia Time per
Unit) $9.30 (specialist) or $8.10 (non-specialist) equals
reimbursement. For purposes of ANES BASIC UNITS calculation, one
unit equals 15 minutes.

1. ALPHABETIC AND NUMERIC SYMBOLS UNDER "IND" & "MOD": These symbols when listed under the "IND" and "MOD" columns are elements of the HCPCS coding system used as qualifiers or indicators (as in the "IND" column) and as modifiers (as in the "MOD" column). They assist the physician or practitioner in determining the appropriate procedure codes to be used, the area to be covered, the minimum requirements needed, and any additional parameters required for reimbursement purposes.

i. These symbols and/or letters must not be ignored because in certain instances requirements are created in addition to the narrative which accompanies the HCPCS code as described in the CPT. THE PROVIDER WILL THEN BE SUBJECT TO THE ADDITIONAL REQUIREMENTS AND NOT JUST THE CPT/HCPCS CODE NARRATIVE. These requirements must be fulfilled in order to receive reimbursement.

ii. If there is no identifying symbol listed, the HCPCS code narrative prevails.

(b) The following statements are requirements for billing and for using HCPCS:

1. When filing a claim, the appropriate HCPCS Codes must be used in conjunction with modifiers, when applicable.

2. The use of a procedure code will be interpreted by the New Jersey Medicaid program as evidence that the physician or practitioner personally furnished, as a minimum, the service for which it stands.

3. For purposes of reimbursement, a physician, practitioner, physicians' group, shared health care facility or physicians sharing a common record are considered a single provider.

4. When billing, the provider must enter a CPT/HCPCS code into the procedure code column field 24-D of the CMS 1500 claim form.

5. Date(s) of service(s) must be indicated on the claim form and in the physician's own record for each service billed.

6. When submitting a claim, the physician or practitioner must always use his/her usual and customary fee. The fees designated for the HCPCS procedure codes represent the New Jersey Medicaid program's maximum payment for the given procedure.

7. All references to time parameters shall mean the physician's or practitioner's personal time in reference to the service rendered unless it is otherwise indicated.

i. Reimbursement will be made for an assistant surgeon when the service is medically necessary and when a duly qualified surgical resident or house physician is unavailable, and when the primary procedure performed has a procedure code specialist fee of at least $142.00. The allowance permitted is a maximum of 15 percent of the listed specialist fee. The minimum payment is $27.00.

ii. When billing for assistant surgery services, affix to the appropriate procedure code the modifier "80" which identifies surgical assistant services.

8. Certain listed procedures are commonly carried out as an integral part of a total service, and, as such, do not warrant a separate charge. Concerning the terminology "separate procedures" when attached to a HCPCS/CPT description, when a procedure is carried out as a separate entity not immediately related to other services, the indicated value for "separate procedure" is applicable.

9. Additional charges on a fee-for-service basis may be reimbursed for complications or other circumstances requiring additional or unusual services concurrent with the procedure(s) or during the listed period of normal follow-up care with a "22" modifier, if so designated with additional documentation accompanying to the claim form.

N.J. Admin. Code § 10:54-9.2

Amended by R.2006 d.237, effective 7/3/2006.
See: 38 N.J.R. 907(a), 38 N.J.R. 2803(a).
In introductory paragraph of (a), substituted "and" for "AND" and updated table ; in (a)1i and (b)8, deleted "-4" following "CPT"; in (b)4, substituted "the CMS" for "HCFA"; and in (b)7i, substituted "$142.00" for "$142" and "$27.00" for "$27".