N.J. Admin. Code § 10:56-2.20

Current through Register Vol. 56, No. 12, June 17, 2024

Section 10:56-2.20 - Consultations

(a) Consultations shall be subject to the following conditions:

1. A written report which includes diagnosis and recommendations for future management shall be provided to the referring practitioner. A copy shall be retained with the beneficiary's records and must be available, upon request, to the New Jersey Medicaid/NJ FamilyCare fee-for-service programs or any of their authorized representatives.

i. When the practitioner rendering the consultation services assumes the continuing care of the beneficiary, any subsequent services rendered by him or her will no longer be considered as consultation.

ii. When consultation services are requested, the referring practitioner shall include on the clinical records the name of the consulting practitioner to whom the beneficiary is being referred. The consulting practitioner shall note the diagnosis under Remarks (Item 20) and the name and the Medicaid/NJ FamilyCare Provider Services number of the referring practitioner on the clinical records and on the Dental Claim Form (MC-10) under Referring Practitioner (Item 14).

iii. A consultation shall be disallowed if either or both diagnosis or referring practitioner is missing. However, an examination may be billed alone or in conjunction with other treatment if the beneficiary makes an appointment on his or her own.

iv. A consultation shall be disallowed if performed on the same beneficiary by the same practitioner, members of the same group, members of a shared health care facility, or practitioners sharing a common record within a 12 month span of a prior claim for the same or related disease, illness or condition.

v. A consultation shall be declined in any setting, if the consultation occurs between members of the same group, shared health care facility, or practitioners sharing common records.

vi. If a consultation is billed in an inpatient setting and the beneficiary is then transferred to the service of the consultant, the consultant shall not bill for a Hospital Call.

N.J. Admin. Code § 10:56-2.20

R.1984 d.270, eff. 7/2/1984.
See: 15 N.J.R. 813(a), 16 N.J.R. 1788(b).
Recodified from 10:56-1.23 and amended by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
In (a)1, inserted references to NJ FamilyCare and to NJ FamilyCare fee-for-service, neutralized gender references, and substituted references to beneficiaries for references to recipients throughout.
Amended by R.2003 d.16, effective 1/6/2002.
See: 34 N.J.R. 2681(a), 35 N.J.R. 232(a).
In (a)1vii, substituted "D9420" for "09420-22".
Amended by R.2007 d.36, effective 2/5/2007.
See: 38 N.J.R. 3419(a), 39 N.J.R. 479(a).
In (a)1ii, substituted "shall" for "must" twice, inserted "and" following "(Item 20)", and deleted "services" following "Dental"; in (a)1iii, (a)1iv and (a)1v, substituted "shall" for "will"; in (a)1vi, substituted "consultant shall" for "consultation may", substituted "Call" For "Day Initial; however, Hospital Day Subsequent -- may be billed for visits on ensuing days"; and deleted (a)1vii.