N.J. Admin. Code § 10:57-2.11

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

Section 10:57-2.11 - Pharmaceutical; podiatrist administered drugs

(a) The New Jersey Medicaid/NJ FamilyCare fee-for-service program shall reimburse podiatrists for certain approved drugs administered intradermally, subcutaneously, intra-muscularly, or intravenously in the office, home, or independent clinic setting according to the following reimbursement methodologies and the requirements of N.J.A.C. 10:51.

1. Podiatrist-administered medications shall be reimbursed directly to the podiatrist under certain situations. (See HCPCS, N.J.A.C. 10:57-3for a listing of HCPCS procedure codes.)

i. A "J" code may be billed in conjunction with an office, home, or independent clinic visit when the criteria for an office or home visit is met and the procedure code is for the method of drug administration.

ii. The Division has assigned HCPCS procedure codes and Medicaid/NJ FamilyCare maximum fee allowances to certain, selected drugs for which reimbursement to the podiatrist is based on the Average Wholesale Price (AWP) of a single dose of an injectable drug, or the podiatrist's acquisition cost, whichever is less.

iii. Unless otherwise indicated in N.J.A.C. 10:57-2, the Medicaid/NJ FamilyCare maximum fee allowance is determined based on the AWP per unit which equals one cubic centimeter (cc) or milliliter (ml) of drug volume for each unit. For drug vials with a volume equal to one cubic centimeter (cc) or milliliter (ml), the Medicaid/NJ FamilyCare maximum fee allowance shall be based on the cost per vial.

iv. A visit for the sole purpose of an injection is reimbursable as an injection and not as an office visit plus an injection. On the other hand, if the criteria of an office or home visit are met, an injection may, if medically indicated, be considered as an add-on to the visit. The drug administered must be consistent with the diagnosis and conform to accepted medical and pharmacological principles in respect to dosage frequency and route of administration.

v. No reimbursement will be made for an injection given as a preoperative medication or as a local anesthetic that is part of an operative or surgical procedure, since this injection would normally be included in the prescribed fee for such a procedure.

2. In situations where a drug required for administration has not been assigned a "J" code or level III HCPCS, the drug shall be prescribed by the podiatrist and obtained from a pharmacy which directly bills the New Jersey Medicaid/NJ FamilyCare program. In this situation, the podiatrist shall bill only for the administration of the drug, using HCPCS 90799.

N.J. Admin. Code § 10:57-2.11

Amended by R.1998 d.248, effective 5/18/1998.
See: 30 N.J.R. 626(a), 30 N.J.R. 1812(b).
In (a)1, changed the N.J.A.C. reference.
Amended by R.1999 d.292, effective 9/7/1999.
See: 31 N.J.R. 1304(a), 31 N.J.R. 2637(a).
In (a), inserted a reference to NJ KidCare fee-for-service programs in the introductory paragraph, and substituted a reference to the Division for a reference to the New Jersey Medicaid program and inserted a reference to NJ KidCare maximum fee allowances in 1ii.
Amended by R.2006 d.240, effective 7/3/2006.
See: 38 N.J.R. 1126(a), 38 N.J.R. 2805(a).
Substituted "FamilyCare" for "KidCare" throughout; and inserted "/NJ FamilyCare" in (a)1iii and in (a)2.

Amended by 53 N.J.R. 1001(b), effective 6/7/2021