N.J. Admin. Code § 10:56-2.5

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

Section 10:56-2.5 - House calls and visits to beneficiary residences

(a) A provider may be reimbursed for a house call/visit (procedure code D9410) in addition to any other services provided on that day. Procedure code D9410 shall include house calls/visits to nursing homes, long-term care facilities, hospice sites, institutions, and other types of extended care facilities.

(b) The following apply to reimbursement for house calls/visits to the facilities identified in (a) above:

1. House calls/visits can be billed in addition to any other services provided to a specific patient on that day; and

2. Billing for house calls/visits using code D9410 shall be limited to once per trip to the facility, regardless of the number of patients examined or treated.

(c) Procedure code D9420, hospital calls, may be reported when providing treatment in the hospital or for operating room cases in the hospital or an ambulatory surgical center, and can be billed in addition to any dental services performed on that day; however, procedure code D9420 shall not be reimbursable if billed in conjunction with a consultation or other hospital calls on the same day. This use of code D9420 requires prior authorization. Prior authorization may be provided when the submitted evidence indicates a hospital, hospital operating room or ambulatory surgical center as the place of service or that the patient has special health needs that require the dental services to be provided in the hospital operating room or ambulatory surgical center. Requests for prior authorization of D9420 shall be submitted to the Division and shall include:

1. A complete pertinent medical history and medical diagnosis;

2. The chief dental complaint;

3. A description of the oral findings pertaining to the present condition, or, if not possible, an explanation as to why no such description is possible;

4. The history of the present dental condition, including all findings; and

5. A record of the working dental diagnosis and the treatment planned for the operating room visit.

(d) Any subsequent hospital calls also require prior authorization. A request for authorization of such subsequent hospital calls may be submitted after the fact, with dates of service noted. The prior authorization for subsequent hospital calls shall include the following information:

1. The diagnosis associated with the need for hospitalization;

2. Any subsequent dental care provided or needed, identified by procedure code;

3. Any changes in the dental diagnosis or treatment plan; and

4. The total number of visits.

N.J. Admin. Code § 10:56-2.5

New Rule, R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Amended by R.2000 d.426, effective 10/16/2000.
See: 32 N.J.R. 2411(a), 32 N.J.R. 3836(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 (c)5, substituted "beneficiary" for "recipient".
Amended by R.2003 d.16, effective 1/6/2003.
See: 34 N.J.R. 2681(a), 35 N.J.R. 232(a).
Rewrote the section.
Amended by R.2007 d.36, effective 2/5/2007.
See: 38 N.J.R. 3419(a), 39 N.J.R. 479(a).
Section was "Visit policies". Rewrote the section.