N.J. Admin. Code § 10:57-3.3
Current through Register Vol. 57, No. 1, January 6, 2025
| IND | HCPCS Code | Mod | Description | S | Maximum Fee Allowance $ | NS |
| G0001 | Routine venipuncture | 1.80 | 1.80 | |||
| QUALIFIER: This service is | ||||||
| reimbursable in the provider office | ||||||
| laboratory (POL) when the specimen | ||||||
| is referred out to an independent | ||||||
| clinical laboratory for testing. | ||||||
| Venipuncture is not reimbursable | ||||||
| when billed by the independent | ||||||
| clinical laboratory. It is | ||||||
| considered all inclusive as part of | ||||||
| the laboratory test. | ||||||
| G0127 | Trimming dystrophic nails, 1-10 | 7.00 | 7.00 | |||
| J0690 | Injection, cefazolin sodium, (ancef, kefzol) up to 500 mg | 2.83 | 2.83 | |||
| J0696 | Injection, ceftriaxone sodium, (rocephin) per 250 mg | 12.97 | 12.97 | |||
| J1100 | Injection, dexamethasone sodium phosphate, up to 4 mg/ml | 0.13 | 0.13 | |||
| J1200 | Injection, diphenhydramine HCl | 0.55 | 0.55 | |||
| (benedryl), up to 50 mg | ||||||
| L1902 | AFO, ankle gauntlet, custom fitted | 48.81 | 48.81 | |||
| L1906 | AFO, multiligaments ankle support | 75.00 | 75.00 | |||
| L1907 | Ankle-foot-orthosis(AFO) | |||||
| Supramalleolar with straps, with or | ||||||
| without interface/pads, custom | ||||||
| fabricated | 353.71 | 353.71 | ||||
| L1930 | AFO, custom fitted, plastic | 156.80 | 156.80 | |||
| L1940 | AFO, molded to patient model, | |||||
| plastic | 387.94 | 387.94 | ||||
| L1951 | AFO, Spiral, Institute of | |||||
| Rehabilitative Medicine type, | ||||||
| Plastic or other material, | ||||||
| prefabricated, includes fitting and | ||||||
| adjustment | 527.61 | 527.61 | ||||
| L1971 | AFO, Plastic or other material with | |||||
| ankle joint, prefabricated, includes | ||||||
| fitting and adjustment | 294.64 | 294.64 | ||||
| L2108 | AFO, fracture orthosis, tibial | 569.60 | 569.60 | |||
| fracture cast orthosis, molded to | ||||||
| patient model | ||||||
| L2112 | AFO, fracture orthosis, tibial | 244.08 | 244.08 | |||
| fracture orthosis, custom fitted | ||||||
| L2114 | AFO, fracture orthosis, tibial | 321.37 | 321.37 | |||
| fracture orthosis, semi-rigid custom | ||||||
| fitted | ||||||
| L2116 | AFO, fracture orthosis, tibial | 366.00 | 366.00 | |||
| fracture orthosis, rigid custom | ||||||
| fitted | ||||||
| L3000 | Foot insert, removable, molded to | 140.00 | 140.00 | |||
| patient model "UCB" type, Berkeley | ||||||
| shell, each | ||||||
| L3001 | Foot insert, removable, molded to | 76.00 | 76.00 | |||
| patient model, Spenco, each | ||||||
| QUALIFIER: Custom Spenco Device | ||||||
| L3002 | Foot insert, removable, molded to | 76.00 | 76.00 | |||
| patient model, Plastazote or equal, | ||||||
| each | ||||||
| L3003 | Foot insert, removable, molded to | 76.00 | 76.00 | |||
| patient model, silicone gel, each | ||||||
| L3010 | Foot insert, removable, molded to | 76.00 | 76.00 | |||
| patient model, longitudinal arch | ||||||
| support, each | ||||||
| QUALIFIER: Any Custom Leather/Metal | ||||||
| Device (Example: Schaeffer, Whitman) | ||||||
| L3020 | Foot insert, removable, molded to | 88.00 | 88.00 | |||
| patient model, longitudinal/ | ||||||
| metatarsal support, each | ||||||
| QUALIFIER: Any Custom Leather/Plastic | ||||||
| Device, Full Foot Only | ||||||
| L3030 | Foot insert, removable, formed to | 48.00 | 48.00 | |||
| patient foot, each | ||||||
| QUALIFIER: Only Off-The Shelf Spenco | ||||||
| L3031 | Foot, Insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each | 80.34 | 80.34 | |||
| L3040 | Foot, arch support, removable, | 29.60 | 29.60 | |||
| premolded, longitudinal, each | ||||||
| QUALIFIER: Only Off-The Shelf | ||||||
| Plastazote | ||||||
| L3050 | Foot, arch support, removable, | 32.00 | 32.00 | |||
| premolded, metatarsal, each | ||||||
| L3060 | Foot, arch support, removable, | 48.00 | 48.00 | |||
| premolded, longitudinal/metatarsal, | ||||||
| each | ||||||
| L3070 | Foot, arch support, nonremovable, | 16.00 | 16.00 | |||
| attached to shoe, longitudinal, each | ||||||
| L3080 | Foot, arch support, nonremovable, | 20.00 | 20.00 | |||
| attached to shoe, metatarsal, each | ||||||
| L3090 | Foot, arch support, nonremovable, | 24.00 | 24.00 | |||
| attached to shoe, longitudinal/ | ||||||
| metatarsal, each | ||||||
| L3100 | Hallus-Valgus night dynamic splint | 20.00 | 20.00 | |||
| L3140 | Foot, rotation positioning device, | 56.00 | 56.00 | |||
| including shoe(s) | ||||||
| L3150 | Foot, rotation positioning device, | 60.00 | 60.00 | |||
| without shoe(s) | ||||||
| L3170 | Foot, plastic heel stabilizer | 112.00 | 112.00 | |||
| L3201 | Orthopedic shoe, oxford with | 48.00 | 48.00 | |||
| supinator or pronator, infant | ||||||
| L3202 | Orthopedic shoe, oxford with | 48.00 | 48.00 | |||
| supinator or pronator, child | ||||||
| L3203 | Orthopedic shoe, oxford with | 48.00 | 48.00 | |||
| supinator or pronator, junior | ||||||
| L3204 | Orthopedic shoe, hightop with | 48.00 | 48.00 | |||
| supinator or pronator, infant | ||||||
| L3206 | Orthopedic shoe, hightop with | 48.00 | 48.00 | |||
| supinator or pronator, child | ||||||
| L3207 | Orthopedic shoe, hightop with | 48.00 | 48.00 | |||
| supinator or pronator, junior | ||||||
| L3208 | Surgical boot, each, infant | 24.00 | 24.00 | |||
| L3209 | Surgical boot, each, child | 24.00 | 24.00 | |||
| L3211 | Surgical boot, each, junior | 24.00 | 24.00 | |||
| L3212 | Benesch boot, pair, infant | 48.00 | 48.00 | |||
| L3213 | Benesch boot, pair, child | 48.00 | 48.00 | |||
| L3214 | Benesch boot, pair, junior | 48.00 | 48.00 | |||
| L3215 | Orthopedic footwear, woman's shoes, oxford | 38.00 | 38.00 | |||
| L3216 | Orthopedic footwear, woman's shoes, depth inlay | 50.00 | 50.00 | |||
| L3217 | Orthopedic footwear, woman's shoes, hightop, depth inlay | 58.00 | 58.00 | |||
| L3219 | Orthopedic footwear, man's shoes, oxford | 38.00 | 38.00 | |||
| L3221 | Orthopedic footwear, man's shoes, depth inlay | 50.00 | 50.00 | |||
| L3222 | Orthopedic footwear, man's shoes, hightop, depth inlay | 58.00 | 58.00 | |||
| L3230 | Orthopedic footwear, custom shoes, depth inlay | 190.00 | 190.00 | |||
| L3250 | Orthopedic footwear, custom molded | |||||
| shoe, removable inner mold, | ||||||
| prosthetic shoe, each | 250.00 | 250.00 | ||||
| L3251 | Foot, shoe molded to patient model, | 280.00 | 280.00 | |||
| silicone shoe, each | ||||||
| L3252 | Foot, shoe molded to patient model, | |||||
| Plastozote (or similar), custom | ||||||
| fabricated, each | 256.00 | 256.00 | ||||
| L3253 | Foot, molded shoe Plastazote (or | |||||
| similar), custom fitted, each | 112.00 | 112.00 | ||||
| L3254 | Nonstandard size or width | 20.00 | 20.00 | |||
| L3255 | Nonstandard size or length | 20.00 | 20.00 | |||
| L3257 | Orthopedic footwear, additional | 50.00 | 50.00 | |||
| charge for split size | ||||||
| L3260 | Ambulatory surgical boot, each | 88.00 | 88.00 | |||
| L3265 | Plastazote sandal, each | 56.00 | 56.00 | |||
| L3300 | Lift, elevation, heel, tapered to metatarsals, per inch | 32.78 | 32.78 | |||
| L3310 | Lift, elevation, heel and | 51.17 | 51.17 | |||
| sole, neoprene, per inch | ||||||
| L3320 | Lift, elevation, heel and sole, cork, | 100.00 | 100.00 | |||
| per inch | ||||||
| L3332 | Lift, elevation, inside shoe, | 44.00 | 44.00 | |||
| tapered, up to one-half inch | ||||||
| L3334 | Lift, elevation, heel, per inch | 23.98 | 23.98 | |||
| L3340 | Heel wedge, Sach | 10.40 | 10.40 | |||
| L3350 | Heel wedge | 12.00 | 12.00 | |||
| L3360 | Sole wedge, outside sole | 12.00 | 12.00 | |||
| L3370 | Sole wedge, between sole | 14.40 | 14.40 | |||
| L3380 | Club foot wedge | 12.00 | 12.00 | |||
| L3390 | Outflare wedge | 16.00 | 16.00 | |||
| L3400 | Metatarsal bar wedge, rocker | 16.00 | 16.00 | |||
| L3410 | Metatarsal bar wedge, between sole | 16.00 | 16.00 | |||
| L3420 | Full sole and heel wedge, between sole | 24.00 | 24.00 | |||
| L3430 | Heel, counter, plastic reinforced | 24.00 | 24.00 | |||
| L3440 | Heel, counter, leather reinforced | 24.00 | 24.00 | |||
| L3450 | Heel, Sach cushion type | 64.00 | 64.00 | |||
| L3455 | Heel, new leather, standard | 8.00 | 8.00 | |||
| L3460 | Heel, new rubber, standard | 8.00 | 8.00 | |||
| L3465 | Heel, Thomas with wedge | 20.00 | 20.00 | |||
| L3470 | Heel, Thomas extended to ball | 24.00 | 24.00 | |||
| L3480 | Heel, pad and depression for spur | 16.00 | 16.00 | |||
| L3485 | Heel, pad, removable for spur | 32.00 | 32.00 | |||
| L3500 | Miscellaneous shoe addition, insole, | 4.00 | 4.00 | |||
| leather | ||||||
| L3510 | Miscellaneous shoe addition, insole, | 8.00 | 8.00 | |||
| rubber | ||||||
| L3520 | Miscellaneous shoe additions, insole, | 8.00 | 8.00 | |||
| felt covered with leather | ||||||
| L3530 | Miscellaneous shoe addition, sole, | 12.00 | 12.00 | |||
| half | ||||||
| L3540 | Miscellaneous shoe addition, sole, | 36.00 | 36.00 | |||
| full | ||||||
| L3550 | Miscellaneous shoe addition, toe tap, | 4.00 | 4.00 | |||
| standard | ||||||
| L3560 | Miscellaneous shoe addition, toe tap, | 6.40 | 6.40 | |||
| horseshoe | ||||||
| L3580 | Miscellaneous shoe addition, convert | 13.60 | 13.60 | |||
| instep to Velcro closure | ||||||
| L3580 | 52 | Velcro straps, attached to a pair of | 14.00 | 14.00 | ||
| shoes, per pair | ||||||
| L3649 | 52 | Foot Casting | 50.00 | 50.00 | ||
| L3649 | 22 | Foot, ankle casting | 65.00 | 65.00 | ||
| L3649 | Orthopedic shoe, modification, addition or transfer, NOS | 28.00 | 28.00 | |||
| L4205 | Repair of orthotic device, quarter- | |||||
| hour rate | 10.60 | 10.60 | ||||
| L5673 | Addition to lower extremity, below | |||||
| knee/above knee, custom fabricated | ||||||
| from existing mold or prefabricated | ||||||
| socket insert, silicone gel, | ||||||
| elastomeric or equal, for use with | ||||||
| locking mechanism | 506.15 | 506.15 | ||||
| L5679 | Addition to lower extremity, below | |||||
| knee/above knee, custom fabricated | ||||||
| from existing mold or prefabricated | ||||||
| socket insert, silicone gel, | ||||||
| elastomeric or equal, not for use | ||||||
| with locking mechanism | 421.77 | 421.77 | ||||
| L5681 | Addition to lower extremity, below | |||||
| knee/above knee, custom fabricated | ||||||
| socket insert for congenital or | ||||||
| atypical traumatic amputee, silicone | ||||||
| gel elastomeric or equal, for use | ||||||
| with or without locking mechanism, | ||||||
| initial only. (For other than initial, | ||||||
| use L5673 or L5679) | 828.47 | 828.47 | ||||
| L5683 | Addition to lower extremity, below | |||||
| knee/above knee, custom fabricated | ||||||
| socket insert for other than | ||||||
| congenital or atypical traumatic | ||||||
| amputee, silicone gel elastomeric or | ||||||
| equal, for use with or without | ||||||
| locking mechanism, initial only. | ||||||
| (For other than initial, use L5673 or | ||||||
| L5679) | 828.47 | 828.47 | ||||
| Q0112 | All potassium hydroxide (KOH) preparations | 0.10 | 0.10 |
N.J. Admin. Code § 10:57-3.3
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 a reference to HCPCS Code G0127, and in HCPCS Codes L3001, L3010, L3020, L3030 and L3040, added references to Qualifiers.
Amended by R.2001 d.63, effective 2/20/2001.
See: 32 N.J.R. 4096(a), 33 N.J.R. 661(b).
Deleted a HCPCS Code M0101.
Amended by R.2001 d.186, effective 6/4/2001.
See: 33 N.J.R. 972(a), 33 N.J.R. 1915(b).
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).
Updated table.