N.J. Admin. Code § 10:58A-4.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:58A-4.1 - Introduction to the HCPCS procedure code system

(a) The New Jersey Medicaid/NJ FamilyCare fee-for-service programs use the Centers for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Code System (HCPCS) for 2009, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act of 1996, Pub.L. 104-191, 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 Physicians' Current Procedure 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. Due to copyright restrictions, the CPT procedure narratives for Level I codes are not included in this subchapter, but are hereby incorporated by reference.

1. Copies of the CPT may be ordered 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/TransactionCodeSetsStands/ 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, advanced practice nurses (APNs), independent clinics and independent laboratories. Level I procedure codes, and fees for each, for which APNs may bill, can be found at 10:58A-4.2.

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 10:58A-4.3.

(c) Specific elements of HCPCS codes require the attention of providers. The lists of HCPCS code numbers for independent clinic 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" and "MAXIMUM FEE ALLOWANCE." The information given under each column is summarized below:

1. Alphabetic and numeric symbols under "IND" & "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 modifiers ("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/NJ
	FamilyCare fee-for-service program's qualifications and
	requirements when a procedure or service code is used.

2. An explanation of the indicators and qualifiers used in this column is located below and in paragraph 1, "Alphabetic and numeric symbols."

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
	program maximum fee allowance, even if the procedure is
	done on the same patient, by the same provider, at the
	same session and also that the procedure codes are
	excluded from the policy indicating that office visit
	codes are not reimbursed in addition to procedure codes
	for surgical procedures. (See 10:58A-4.5(a) ).
L =	"L" preceding any procedure code indicates that the
	complete narrative for the code is located at N.J.A.C.
	10:58A-4.4(b) and 4.5(c).
N =	"N" preceding any procedure code means that qualifiers
	are applicable to that code. These qualifiers are listed
	by procedure code number at 10:58A-4.5.
P =	"P" preceding any procedure code indicates that prior
	authorization is required. The appropriate form that must
	be used to request prior authorization is indicated in
	the Fiscal Agent Billing Supplement.
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 fee-for-service programs' modifier codes for
	certified nurse practitioner/certified clinical nurse
	specialist services are:
EP =	Services provided to Medicaid/NJ FamilyCare
	fee-for-service beneficiaries under 21 years of age under
	Early Periodic Screening, Diagnosis and Treatment Program
	(EPSDT) as set forth at 10:58A-2.11.
SA =	Advanced Practice Nurse.
TC =	Technical component: When applicable, a charge may be
	made for the technical component alone. Under these
	circumstances, the technical component charge is
	identified by adding the modifier "TC" to the usual
	procedure code.
UD =	Abortion-related services
22 =	Unusual services: When the service provided is greater
	than that usually required for the listed procedure, it
	may be identified by adding the modifier "22" to the
	usual procedure number.
26 =	Professional Component: Certain procedures are a
	combination of a professional and a technical component
	When the professional component is reported separately,
	the service may be identified by adding the modifier "26"
	to the usual procedure number. If a professional type
	service is keyed without a "26" modifier and a manual
	pricing edit is received, resolve the edit by adding a 26
	modifier.
50 =	Bilateral procedures: Unless otherwise identified in
	the listings, bilateral procedures requiring a separate
	incision which are performed during 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 code.
52 =	Reduced services: Under certain circumstances, a
	service or procedure is partially reduced or eliminated
	at the practitioner'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.

DESCRIPTION = Code narrative:

Narratives for Level I codes are found in CPT.

Narratives for Level II and III codes are found at 10:58A-4.3 and 4.4, respectively.

FOLLOW-UP DAYS = Number of days for follow-up care which are considered as included as part of the procedure code for which no additional reimbursement is available.

MAXIMUM FEE ALLOWANCE = New Jersey Medicaid/NJ FamilyCare fee-for-service program's maximum reimbursement allowance. If the symbols "BR" (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.

(d) Listed below are general policies of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs that pertain to HCPCS. Specific information concerning the responsibilities of an APN when rendering Medicaid/NJ FamilyCare fee-for-service covered services and requesting reimbursement are located at N.J.A.C. 10:58A-1.4, Recordkeeping; 1.5, Basis of reimbursement; and 2.7, Evaluation and management services.

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. (10:58A-4.2 and 4.3.)

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 APN. When submitting a claim, the APN shall enter the APN's 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 10:58A-4.5, 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 fee-for-service program as evidence that the APN personally furnished, as a minimum, the services for which it stands.

vii. For reimbursement purposes, those services with the modifier "SA" must be personally performed by the APN who is submitting the claim.

N.J. Admin. Code § 10:58A-4.1

Amended by R.2000 d.144, effective 4/3/2000.
See: 31 N.J.R. 3968(a), 32 N.J.R. 1208(a).
In (c)1, substituted a reference to CPT for a reference to CPT-4 in i, inserted a reference to NJ KidCare programs in IND description, and inserted a reference to "E".
Amended by R.2000 d.265, effective 7/3/2000.
See: 32 N.J.R. 1127(a), 32 N.J.R. 2483(a).
Inserted references to NJ KidCare fee-for-service and substituted references to CPT for references to CPT-4 throughout; in (a), deleted a reference to the American Medical Association and substituted a reference to this subchapter for a reference to this manual in the introductory paragraph, and added 1; and in (c), inserted references to TC and 26.
Amended by R.2004 d.334, effective 9/7/2004.
See: 36 N.J.R. 312(a), 36 N.J.R. 4136(a).
Amended by R.2004 d.409, effective 11/1/2004.
See: 35 N.J.R. 4977(a), 36 N.J.R. 4968(a).
Rewrote (a); in (b)2, substituted "CMS" for "HCFA".
Amended by R.2005 d.406, effective 11/21/2005.
See: 37 N.J.R. 2329(a), 37 N.J.R. 4445(a).
Rewrote the section.
Amended by R.2011 d.119, effective 4/18/2011.
See: 42 N.J.R. 2890(a), 43 N.J.R. 1015(a).
Rewrote (a); in the introductory paragraph of (b), substituted "two" for "three"; in (b)1, inserted "(APNs)"; deleted (b)3; in the introductory paragraph of (d), deleted "10:58A-" preceding "1.5" and "2.7"; and substituted "reimbursement" for "Reimbursement" and "management services" for "Management Services"; and in (d)1ii, substituted "and" for a comma following "4.2", and deleted ", 4.4" following "4.3".

Amended by 56 N.J.R. 2191(a), effective 11/4/2024