N.J. Admin. Code § 10:77-7.1

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

Section 10:77-7.1 - Introduction

(a) The New Jersey Medicaid NJ FamilyCare programs utilize the Centers for Medicare and Medicaid Services (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. CPT is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical procedures and services performed by physicians. Unlike the CPT numeric design, the CMS-assigned codes and modifiers contain alphabetic characters. The New Jersey Medicaid/NJ FamilyCare program adopted the Centers for Medicare and Medicaid Services 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-1 et seq. The HCPCS codes as listed in this subchapter are relevant to Medicaid and NJ FamilyCare fee-for-services rehabilitation services for children and must be used when filing a claim. An updated copy of the HCPCS codes may be obtained by accessing www.njmmis.com.

(b) 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, certified nurse practitioners/clinical nurse specialists, independent clinics and independent laboratories. Copyright restrictions make it impossible to print excerpts from CPT procedure narratives for Level I codes. Thus, in order to determine those narratives, it is necessary to refer to CPT, which is incorporated herein by reference.

2. LEVEL II CODES: The narratives for Level II codes are found in this subchapter. These codes are not found in the CPT and are assigned by HCFA for use by physicians and other practitioners.

(c) Regarding specific elements of HCPCS codes, which require the attention of providers, the lists of HCPCS code numbers for rehabilitative 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. "IND"--(Indicator) Lists alphabetic symbols used to refer provider to information concerning the New Jersey Medicaid/NJ FamilyCare program's qualifications and requirements when a HCPCS procedure code is used.

i. A "P" indicates that prior authorization is required for that procedure code. A valid authorization number must be included on the claim form when seeking reimbursement for the provision of the service.

2. "HCPCS Code"--Lists the HCPCS procedure code numbers;

3. "DESCRIPTION"--Code narrative: Narratives for Level III codes are found at N.J.A.C. 10:77-7.2;

4. "MAXIMUM FEE ALLOWANCE"--Lists the New Jersey Medicaid/NJ FamilyCare programs maximum fee allowance schedule. If the symbol "B.R." (By Report) is listed instead of a dollar amount, it means that additional information will be required in order to properly evaluate the service. Attach a copy of the report to the claim form. If the symbol "N.A." (Not Applicable) is listed instead of a dollar amount, it means that service is not reimbursable.

5. "MOD" services and procedures may be modified under certain circumstances. When applicable, the modifying circumstances are identified by the addition of a two-digit code following the HCPCS procedure number. The New Jersey Medicaid/NJ FamilyCare program's recognized modifier codes for behavioral assistance services are as follows:

HQ: Services provided in a group setting.

TJ: Program group, child and/or adolescent.

UN: Group services; two patients served.

UP: Group services; three patients served.

U1: Level of care 1 - residential care supervision

U2: Level of care 2 - residential care supervision

U3: Level of care 3 - residential care supervision

(d) Listed below are both general and specific policies of the New Jersey Medicaid/NJ FamilyCare program that pertain to HCPCS:

1. When filing a claim, the appropriate HCPCS Codes shall be used in conjunction with modifiers, when applicable;

2. The use of a procedure code shall be interpreted by the New Jersey Medicaid/NJ FamilyCare program as evidence that the provider personally furnished, as a minimum, the service for which it stands;

3. When billing, the provider shall enter onto a CMS 1500 claim form, a CPT/HCPCS procedure code as listed in CPT or in this subchapter;

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

5. The "MAXIMUM FEE ALLOWANCE" as noted with these procedure codes represents the maximum amount a provider can be reimbursed for the given procedure;

i. All references to time parameters shall mean the provider's personal time in reference to the service rendered unless it is otherwise indicated. These procedure codes are all-inclusive for all procedures provided during that time;

6. Written records in substantiation of the use of a given procedure code shall be available for review and/or inspection if requested by the Division or its fiscal agent; and

7. Certain listed procedures are commonly carried out as an integral part of a total service, and, as such, do not warrant a separate charge. When "Separate Procedure" is attached to a HCPCS/CPT description, indicating that a procedure may be carried out as a separate entity not immediately related to a specific service, separate charges for the procedure and reimbursement are applicable.

N.J. Admin. Code § 10:77-7.1

Amended by 48 N.J.R. 81(a), effective 1/4/2016