N.J. Admin. Code § 10:58-1.10

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

Section 10:58-1.10 - Recordkeeping; initial visit

(a) In order to receive reimbursement for an initial visit, the following documentation, at a minimum, shall be on the record, regardless of the setting where the examination was performed:

1. The chief complaint(s);

2. A complete history of the present illness and related systemic review-- including recordings of pertinent negative findings;

3. A pertinent past medical history;

4. A pertinent family history;

5. A full physical examination pertaining to, but not limited to, the history of the present illness and including recordings of pertinent negative findings; and

6. The working diagnoses and treatment plan including ancillary services and drugs ordered.

N.J. Admin. Code § 10:58-1.10

Recodified from N.J.A.C. 10:58-1.9 by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Former N.J.A.C. 10:58-1.10, Recordkeeping; routine or follow-up visits, recodified to N.J.A.C. 10:58-1.11.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.