N.J. Admin. Code § 10:75-5.1

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

Section 10:75-5.1 - Introduction

(a) The New Jersey Medicaid/NJ FamilyCare program utilizes the Centers for Medicare and Medicaid Services' 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 the CPT for utilization primarily by Physicians, Certified Nurse Practitioners 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.

i. Copyright restrictions make it impossible to print excerpts from the CPT procedure narratives for Level I codes. Thus, in order to determine those narratives, it is necessary to refer to the CPT, which is incorporated herein by reference, as amended and supplemented. The CPT is available in medical bookstores or may be obtained by contacting the American Medical Association at 515 North State Street, Chicago, IL 60610, telephone: 312-464-5000, website: www.ama-assn.org.

2. Level II Codes: These codes are assigned for physicians and non-physician services that are not found in the CPT.

(b) Regarding specific elements of HCPCS procedure codes which require the attention of the provider, the lists of HCPCS code numbers are arranged in tabular form with specific hospital or program information for a code identified under columns with titles such as: "IND," "HCPCS CODE," "MOD," "DESCRIPTION," and "MAXIMUM FEE ALLOWANCE." The program information identified under each column is summarized below:

ColumnTitle	Description
IND	(Indicator) Lists alphabetic symbols used to refer
provider to hospital or program information concerning
the New Jersey Medicaid/NJ FamilyCare fee-for-service
program's qualifications and requirements when a
procedure or service code is used. Explanation of
indicators and qualifiers used in this column are
identified below.
HCPCS Code	Lists the HCPCS procedure code numbers.
Mod	Lists alphabetic and numeric symbols. Services and
procedures may be modified under certain circumstances.
When applicable, the modifying circumstance should be
identified by the addition of alphabetic and/or numeric
characters at the end of the code.
Description	Lists the code narrative. (Narratives for Level I codes
are found in CPT.)
Maximum FeeAllowance	Lists the New Jersey Medicaid/NJ FamilyCare
fee-for-service program's maximum reimbursement
schedule for the defined services.

(c) 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 physician/practitioner 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/or letters shall not be ignored because, in certain instances, requirements are created in addition to the narrative that accompanies the CPT/HCPCS procedure code as written in CPT. The provider will then be liable for the additional requirements and not just the CPT/HCPCS procedure code narrative. These requirements shall be fulfilled in order to receive reimbursement.

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

N.J. Admin. Code § 10:75-5.1

Amended by 49 N.J.R. 101(a), effective 1/3/2017