N.J. Admin. Code § 10:64-3.1

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

Section 10:64-3.1 - Introduction to the HCPCS procedure code system

(a) The New Jersey Medicaid/NJ FamilyCare program uses the Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 1320d et seq., and incorporated herein by reference, as amended and supplemented, and 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 chapter 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-1et seq.

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

1. Level I codes: Narratives for these codes are found in the CPT, which is incorporated herein by reference, as amended and supplemented. The codes are adapted from the 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 are not applicable to hearing aid services.

2. Level II codes: These codes are assigned by CMS for physician and non-physician services which are not in the CPT. Narratives for these codes, and the fees for each, can be found at N.J.A.C. 10:64-3.2.

3. Level III codes: Level III codes identify services unique to the New Jersey Medicaid program. These codes are assigned by the Department to be used for those services not identified by CPT codes or CMS-assigned codes. Narratives for these codes, and the fees paid for each, can be found at N.J.A.C. 10:64-3.3.

(c) Specific elements of HCPCS codes require the attention of providers. The lists of HCPCS code numbers for hearing aid services are arranged in tabular form with specific information for a code given under columns with titles such as: "IND," "HCPCS CODE," "MOD," "DESCRIPTION," and "MAXIMUM FEE ALLOWANCE." 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 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-4, 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 program's 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:
N =	"N" preceding any procedure code means that qualifiers are applicable to that code. These qualifiers are listed by HCPCS procedure code number at N.J.A.C. 10:64-3.4.
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/NJ FamilyCare program's modifier codes for hearing aid services are: LT = Left side (used to identify procedures performed on the left side of the body). RT = Right side (used to identify procedures performed on the right side of the body). YF = Dispenser's service fee.
DESCRIPTION =	Code narrative: Narratives for Level I codes are found in CPT-4. Narratives for Level II and III codes are found at N.J.A.C. 10:64-3.2 and 3.3
MAXIMUM FEE ALLOWANCE =	New Jersey Medicaid/NJ FamilyCare program's maximum 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 (for example: Invoice or manufacturer's price list where appropriate, or detailed description of service for minor in-office procedure).

(d) Listed below are general policies of the New Jersey Medicaid/NJ FamilyCare program that pertain to HCPCS. Specific information concerning the responsibilities of a hearing aid service when rendering Medicaid/NJ FamilyCare-covered services and requesting reimbursement are located at N.J.A.C. 10:64-1 and 2.

1. General requirements are as follows:

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

ii. When billing, the provider shall enter on the claim form a CPT/HCPCS procedure code as listed in this subchapter (N.J.A.C. 10:64-3.2 and 3.3).

iii. Date(s) of service(s) shall 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 hearing aid service. When submitting a claim, the provider shall always use her or his usual and customary fee.

N.J. Admin. Code § 10:64-3.1

Amended by R.2006 d.289, effective 8/21/2006.
See: 38 N.J.R. 1385(a), 38 N.J.R. 3304(a).
Rewrote (a); in (b), substituted "the CPT" for "CPT-4" in three places, substituted "CPT" for "CPT-4", and "substituted "CMS" for "HCFA" in two places.

Amended by 53 N.J.R. 2222(a), effective 12/20/2021