N.J. Admin. Code § 10:62-3.1

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

Section 10:62-3.1 - Introduction

(a) The New Jersey Medicaid/NJ FamilyCare fee-for-service programs utilize the CMS Healthcare Common Procedure Coding System (HCPCS). HCPCS follows the American Medical Association's Physicians' Current Procedural Terminology (CPT) architecture, employing a five-position code and as many as two 2-position modifiers. Unlike the CPT numeric design, the CMS assigned codes and modifiers contain alphabetic characters. HCPCS is a two-level coding system.

1. Level I Codes (Narratives found in CPT): These codes are adapted from CPT for utilization primarily by Physicians, Podiatrists, Optometrists, Certified Nurse-Midwives, Independent Clinics and Independent Laboratories. CPT is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians. Copyright restrictions make it impossible to print excerpts from CPT procedure narrative for Level I codes. Thus, in order to determine those narratives it is necessary to refer to CPT, which is incorporated herein by reference, as amended and supplemented. (The CPT is available from the Order Department of the American Medical Association, PO Box 109050, Chicago, Illinois 60610.)

2. Level II Codes (Narratives found in N.J.A.C. 10:62-3.5) : These codes are assigned by CMS for physician and non-physician services which are not in CPT.

3. Level III Codes (Narratives found in N.J.A.C. 10:62-3.3 and 3.5): These codes are assigned by the Division to be used for those services not identified by CPT codes or CMS-assigned codes. Level III codes identify services unique to New Jersey.

(b) The HCPCS procedure codes listed in this subchapter are divided into two sections: HCPCS procedure codes for professional services are in N.J.A.C. 10:62-3.2; and HCPCS procedure codes for vision care appliances are in N.J.A.C. 10:62-3.5.

(c) The responsibility of the provider when rendering professional services and requesting reimbursement is listed in N.J.A.C. 10:62-1, Reimbursement Policies; for optical appliances, N.J.A.C. 10:62-2, Reimbursement Policies.

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

2. The use of a HCPCS procedure code will be interpreted by the New Jersey Medicaid/NJ FamilyCare fee-for-service programs as evidence that the practitioner personally furnished, at a minimum, the service which the code represents.

3. For reimbursement purposes, when reference is made to any of the following services it is understood that they were performed by the practitioner submitting the claim:

i. Office, hospital, nursing home, or residential health care facility visits; and

ii. Any and all parts of a history or eye examination.

4. Date(s) of service(s) shall be indicated on the claim form and in the practitioner's own record for each service billed.

5. When submitting a claim, the practitioner shall always use the practitioner's usual and customary fee. The New Jersey Medicaid/NJ FamilyCare fee-for-service dollar value designated for the HCPCS procedure codes represents the New Jersey Medicaid/NJ FamilyCare fee-for-service programs' maximum payment for the given procedure.

i. All references to time parameters shall mean the practitioner's time in reference to the service rendered unless it is otherwise indicated.

(d) Regarding specific elements of HCPCS procedure codes which require attention of providers, the lists of HCPCS procedure codes for vision care services are arranged in tabular form with specific information for a code identified under columns with titles such as: "IND," "HCPCS CODE," "MOD," "DESCRIPTION," AND "MAXIMUM FEE ALLOWANCE." The information identified under each column is summarized below:

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(e) Regarding 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 (as in the "IND" column) and as modifiers (as in the "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.

1. These symbols and letters must not be ignored because, in certain instances, requirements are created in addition to the narrative that accompanies the HCPCS procedure code as written in CPT. The provider must be careful to enter the additional requirements, and not just the HCPCS procedure code narrative. These requirements must be fulfilled in order to receive reimbursement.

2. If there is no identifying symbol listed, the HCPCS procedure code narrative prevails.

(f) For surgical codes relevant to Ophthalmologists see Physicians Services Chapter (N.J.A.C. 10:54-4, CMS Healthcare Common Procedure Coding System).

N.J. Admin. Code § 10:62-3.1

Amended by 49 N.J.R. 2279(b), effective 7/17/2017