N.J. Admin. Code § 10:57-3.1

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:57-3.1 - Introduction to the HCPCS procedure coding system

(a) The New Jersey Medicaid and NJ FamilyCare programs use the Federal Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act, of 1996, 42 USC § 1320d et seq., and incorporated herein by reference, as amended and supplemented, and as published by PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010. Revisions to the Healthcare Common Procedure Coding System made by CMS (code additions, code deletions, and replacement codes) will be reflected in this subchapter through publication of a notice of administrative change in the New Jersey Register. Revisions to existing reimbursement amounts specified by the Department and specification of new reimbursement amounts for new codes will be made by rulemaking in accordance with the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. HCPCS follows the American Medical Association's Physician's Current Procedural Terminology CPT architecture, employing a five-position code and as many as two two-position modifiers. Unlike the CPT numeric design, the CMS-assigned codes and modifiers contain alphabetic characters. Because of copyright restrictions, the CPT procedure narratives for Level I codes are not included in this manual, but are incorporated herein by reference, as amended and supplemented. An updated copy of the CPT (Level I) codes may be obtained from the American Medical Association, P.O. Box 10950, Chicago, IL 60610, or by accessing http://www.ama-assn.org. An updated copy of the HCPCS (Level II) codes may be obtained by accessing the HCPCS website at http://www.cms.hhs.gov/medicare/hcpcs or by contacting PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010.

(b) HCPCS has been developed as a two-level coding system, as follows:

1. Level I codes: Narratives for these codes are found in CPT, which is incorporated herein by reference, as amended and supplemented. The codes are adapted from CPT for use primarily by physicians, podiatrists, optometrists, certified nurse-midwives, certified nurse practitioners and clinical nurse specialists, independent clinics and independent laboratories. Level I procedure codes, and fees for each, for which podiatrists may bill, can be found at N.J.A.C. 10:57-3.2.

2. Level II codes: These codes are assigned by CMS for physician and non-physician services which are not in CPT. Narratives for these codes, and the fees for each, can be found at N.J.A.C. 10:57-3.3.

(c) Specific elements of HCPCS codes require the attention of providers. The lists of HCPCS code numbers for podiatric services are arranged in tabular form with specific information for a code given under columns with titles such as: "IND," "HCPCS CODE," "MOD," "DESCRIPTION," "FOLLOW-UP DAYS," "MAXIMUM FEE ALLOWANCE" and "ANES BASIC UNITS." The information given under each column is summarized below:

1. Alphabetic and numeric symbols under "IND" and "MOD":

These symbols, when listed under the "IND" and "MOD" columns, are elements of the HCPCS coding system used as qualifiers or indicators ("IND" column) and as modified ("MOD" column). They assist the provider 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 shall not be ignored because they reflect requirements, in addition to the narrative which accompanies the CPT/HCPCS procedure code as written in the CPT, for which the provider is liable. These additional requirements shall be fulfilled before reimbursement is requested.

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

IND =	lists alphabetic symbols used to refer the provider to
information concerning the New Jersey Medicaid or NJ
FamilyCare programs' qualifications and requirements when
a procedure or service code is used. An explanation of the
indicators and qualifiers used in this column is located
below and in paragraph 1, "Alphabetic and numeric symbols,"
as follows:
A =	"A" preceding any procedure code indicates that these tests
can be and are frequently done as groups and combinations
(profiles) on automated equipment.
D =	"D" preceding any procedure code indicates that the procedure
code is excluded from the requirement that office visit codes
not be reimbursed in addition to procedure codes for surgical
procedures performed in the office.
E =	"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/NJ FamilyCare maximum fee allowance, even if the
procedure is done on the same patient by the same surgeon at
the same operative session.
L =	"L" preceding any procedure code indicates that the complete
narrative for the code is located in N.J.A.C. 10:57-3.3.
N =	"N" preceding any procedure code means that qualifiers are
applicable to that code. (See N.J.A.C. 10:57-3.4.)
HCPCS
CODE =	HCPCS procedure code numbers.
MOD =	Alphabetic and numeric symbols: Under certain circumstances,
services and procedures may be modified by the addition of
alphabetic and/or numeric characters at the end of the code.
The New Jersey Medicaid and NJ FamilyCare programs' modifier
codes for podiatry services are:
22 =	Unusual Services: When the service(s) provided is greater than
that usually required for the listed procedure, it may be
identified by adding modifier '22' to the usual procedure
number.
26 =	Professional Component: Certain procedures are a combination
of a physician and a technical component. When the physician
component is reported separately, the service may be
identified by adding the modifier '26' to the usual procedure
number. If a professional component type service is keyed
without the '26' modifier and a manual pricing edit is
received, resolve the edit by adding the '26' modifier.
50 =	Bilateral Procedure: Unless otherwise identified in the
listing, bilateral procedures requiring separate incisions
that are performed at the same operative session, should be
identified by the appropriate five-digit code describing the
first procedure. The second (bilateral) procedure is
identified by adding modifier '50' to the procedure number.
51 =	Multiple Procedures: When multiple procedures are performed
at the same operative session, the major procedure may be
reported as listed. The secondary, additional or lesser
procedure(s) may be identified by adding the modifier '51'
to the secondary procedure number(s).
52 =	Reduced Services: Under certain circumstances, a service or
procedure is partially reduced or eliminated at the
podiatrist's election. Under these circumstances the service
provided can be identified by its usual procedure number and
the addition of the modifier '52' signifying that the service
is reduced. This provides a means of reporting reduced
services without disturbing the identification of the basic
service.
62 =	Two Surgeons: Under certain circumstances, the skill of two
surgeons (usually with different skills) may be required in
the management of a specific procedure. Under such
circumstances the separate services may be identified by
adding the modifier '62' to the procedure number used by
each surgeon for reporting his or her services.
66 =	Surgical Team: Under some circumstances, highly complex
procedures (requiring the concomitant services of several
physicians or podiatrists, often of different specialties,
plus other highly skilled, specially trained personnel and
various types of complex equipment) are carried out under
the "surgical team" concept. Such circumstances may be
identified by each participating physician or podiatrist
with the addition of the modifier '66' to the basic procedure
number used for reporting services.
76 =	Repeat Procedure By Same Podiatrist: The podiatrist may need
to indicate that a procedure or service was repeated
subsequent to the original service. This circumstance may be
reported by adding the modifier '76' to the repeated service.
77 =	Repeat Procedure By Another Podiatrist: The podiatrist may
need to indicate that a basic procedure performed by another
podiatrist had to be repeated. This situation may be reported
by adding modifier '77' to be repeated service.
80 =	Assistant Surgeon: Surgical assistant services are identified
by adding this modifier '80' to the usual procedure number(s).
81 =	Minimum Assistant Surgeon.
82 =	Assistant Surgeon (when a qualified resident surgeon is not
available).
TC =	When applicable, a charge may be made for the technical
component alone. Under those circumstances the technical
component is identified by adding the modifier 'TC' to the
usual procedure code.
DESCRIPTION =	Code narrative:
Narratives for Level I codes are found in CPT. Narratives
for Level II Codes are found at N.J.A.C. 10:57-3.3.
FOLLOW-UP	Number of days for follow-up care which are considered as
DAYS =	included as part of the procedure code for which no additional
reimbursement is available.
MAXIMUM FEE	New Jersey Medicaid/NJ FamilyCare program's maximum
ALLOWANCE =	reimbursement allowance. If the symbols "B.R." (By Report)
are listed instead of a dollar amount, it means that
additional information will be required in order to evaluate
and price the service. Attach a copy of any additional
information to the claim form.
ANES BASIC	B.U.V. (Basic Unit Value) + A.T. (Anesthesia Time Per Unit)
UNITS =	x $9.30 (Specialist) or $8.10 (non-specialist) equals
reimbursement. Anesthesia Time per Unit is 15 minutes =
1 unit.

(d) Listed in this subsection are general policies of the New Jersey Medicaid/NJ FamilyCare program that pertain to HCPCS. Specific information concerning the responsibilities of a podiatrist when rendering Medicaid/NJ FamilyCare fee-for-service covered services and requesting reimbursement are located at N.J.A.C. 10:57-1.8, Recordkeeping, and 1.6, Basis of reimbursement.

1. General requirements are as follows:

i. When filing a claim, the appropriate HCPCS procedure codes must be used, in conjunction with modifiers when applicable.

ii. When billing, the provider must enter on the claim form a CPT/HCPCS procedure code as listed in this subchapter.

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

iv. The "Maximum Fee Allowance" as noted with these procedure codes represents the maximum payment for the given procedure for the podiatrist. When submitting a claim, the podiatrist must always use her or his usual and customary fee.

(1) Listed values for all surgical procedures include the surgery and the follow-up care included in the maximum fee allowance for the period (indicated in days) in the column titled "Follow-Up Days."

v. The HCPCS procedure codes that are billable in conjunction with office visit codes are listed at N.J.A.C. 10:57-3.4, Qualifiers. (See the "N" designation in the "Indicator" column.)

vi. The use of a procedure code will be interpreted by the New Jersey Medicaid/NJ FamilyCare program as evidence that the practitioner personally furnished, as a minimum, the services for which it stands.

N.J. Admin. Code § 10:57-3.1

Amended by R.1998 d.248, effective 5/18/1998.
See: 30 N.J.R. 626(a), 30 N.J.R. 1812(b).
Updated HCPCS codes throughout.
Amended by R.1999 d.292, effective 9/7/1999.
See: 31 N.J.R. 1304(a), 31 N.J.R. 2637(a).
Inserted references to NJ KidCare programs throughout; in (c)1, inserted a reference to Medicare/NJ KidCare beneficiaries; and in (d), inserted a reference to NJ KidCare fee-for-service covered services.
Amended by R.2001 d.186, effective 6/4/2001.
See: 33 N.J.R. 972(a), 33 N.J.R. 1915(b).
Rewrote (c).
Amended by R.2004 d.2, effective 1/5/2004.
See: 35 N.J.R. 3799(a), 36 N.J.R. 188(a).
Rewrote the section.
Amended by R.2006 d.240, effective 7/3/2006.
See: 38 N.J.R. 1126(a), 38 N.J.R. 2805(a).
Section was "Introduction to the HCPCS procedure code system". Rewrote section.

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