N.J. Admin. Code § 10:77A-3.1

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

Section 10:77A-3.1 - Introduction

(a) The New Jersey Medicaid/NJ FamilyCare programs use 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. The 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 may contain alphabetic characters.

(b) HCPCS is a two-level coding system, as follows:

1. LEVEL I CODES (narratives found in the CPT): These codes are adapted from the Physicians Current Procedural Terminology, as amended and supplemented, published by the American Medical Association, 515 N. State Street, Chicago, IL 60610, incorporated herein by reference. The CPT codes are used primarily by physicians, podiatrists, optometrists, certified nurse-midwives, advanced practice nurses, independent clinics and independent laboratories. Copyright restrictions make it impossible to print substantial excerpts from CPT procedure narratives for Level I codes. Thus, in order to determine those narratives, it is necessary to refer to the CPT.

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 CMS 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 services are arranged in tabular form with specific information for a code given under columns with titles, such as "HCPCS Code," "DESCRIPTION" and "MAXIMUM FEE ALLOWANCE." The information given under each column is summarized below:

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

2. "DESCRIPTION--Code narrative: Complete narratives for the codes are found at 10:77A-2.2;

3. "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 the service is not reimbursable.

(d) 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.

1. Providers shall consider these symbols and letters when billing because the symbols/letters reflect requirements, in addition to the narrative that accompanies the CPT/HCPCS procedure code, for which the provider is liable. These additional requirements shall be fulfilled before reimbursement is requested.

i. "52" Reduced Services: Under certain circumstances a service or procedure is partially reduced or modified. 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 or modified. This provides a means of reporting reduced services without disturbing the identification of the basic service. In this chapter, the "52" modifier indicates that AMHR services are rendered in a supervised apartment setting rather than in a group home setting.

(e) The general and specific requirements of the New Jersey Medicaid/NJ FamilyCare programs that pertain to HCPCS follow:

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 programs as evidence that the provider 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 will 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 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 of Medical Assistance and Health Services, the Department of Human Services, or any contracted and authorized agent of the Department.

N.J. Admin. Code § 10:77A-3.1

Amended by 49 N.J.R. 201(b), effective 1/17/2017