reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 3 - PROCEDURES FOR DETERMINING CLINICAL ELIGIBILITY FOR PMDC SERVICES › Section 10:60A-3.5 - Fair hearing for Medicaid/NJ FamilyCare beneficiaries who are denied PMDC

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Medicaid/NJ FamilyCare beneficiary may appeal a determination of clinical ineligibility made by the Division pursuant to N.J.A.C. 10:60A-3.4.
(b) To initiate an appeal, the Medicaid/NJ FamilyCare beneficiary must submit a request for a fair hearing pursuant to N.J.A.C. 10:49-10 and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.
(c) A request for an administrative hearing shall be considered timely filed if it is submitted within 20 days of the date of issuance to the beneficiary's parent of notice of the determination by professional staff designated by the Department of the child's clinical ineligibility for PMDC.
(d) At the administrative hearing, the burden is upon the Medicaid/NJ FamilyCare beneficiary to demonstrate clinical eligibility for PMDC.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 4 - BASIS OF PAYMENT › Section 10:60A-4.1 - Reimbursement rate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In accordance with P.L. 2016, c. 10, the per diem reimbursement rate for PMDC for fiscal year 2017 is $ 330.81 (base reimbursement rate), as amended and supplemented by subsequent State appropriations acts.
1. The Department shall rebase the base reimbursement rate every three years using data regarding median allowable costs the Department collects in PMDC facility cost reports and financial statements.
2. In years during which the Department does not rebase the base reimbursement rate, the Department shall calculate the per diem reimbursement rate payable to all PMDC facilities by multiplying the base reimbursement rate by the inflation adjustment factor.
3. The Department shall develop the inflation adjustment factor upon consideration of:
i. The average hourly earnings of manufacturing employees in New Jersey as published by the United States Department of Labor, Bureau of Labor Statistics;
ii. The Consumer Price Index as published by the United States Department of Labor, Bureau of Labor Statistics; and
iii. Other standards imposed by law or regulation governing rate-setting methodology in Medicaid/NJ FamilyCare programs.
4. The Department shall publish a notice of revisions to the PMDC base reimbursement rate, per diem reimbursement rate, and/or inflation adjustment factor in the New Jersey Register by no later than February 1 of the fiscal year immediately preceding the fiscal year for which the revision is to be in effect.
5. The requirements of (a)1 through 4 above shall not apply in any State fiscal year for which the PMDC rate is established in the State appropriations act.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 4 - BASIS OF PAYMENT › Section 10:60A-4.2 - Billing codes

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare Program uses the CMS Healthcare Common Procedure Coding System (HCPCS).
1. The HCPCS codes for PMDC are as follows:
Z1863
Pediatric medical day care facility visit for a technology-dependent child
Z1864
Pediatric medical day care facility visit for a medically complex child
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 5 - PMDC SERVICES › Section 10:60A-5.1 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A PMDC beneficiary attending a PMDC facility shall receive one unit of service per day, excluding transportation time, not to exceed five units of service per week, in accordance with a primary health care provider's written order and authorization by professional staff designated by the Department pursuant to N.J.A.C. 10:60A-3.4.
(b) A PMDC facility shall be equipped and staffed to accommodate no fewer than six medically complex children and/or technology-dependent children in accordance with N.J.A.C. 8:43J.
(c) All prescribed therapies shall be included in the interdisciplinary plan of care and shall be provided according to the written, dated and signed orders of the PMDC beneficiary's primary health care provider.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 5 - PMDC SERVICES › Section 10:60A-5.2 - PMDC facility services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To receive Medicaid/NJ FamilyCare reimbursement for PMDC, a PMDC facility shall provide services pursuant to N.J.A.C. 8:43J.
(b) In addition to the services PMDC facilities must provide pursuant to (a) above, to receive Medicaid/NJ FamilyCare reimbursement for PMDC, PMDC facilities shall provide, on-site, medical equipment and supplies in accordance with N.J.A.C. 8:43J-8.5, provided that Medicaid/NJ FamilyCare per diem reimbursement for PMDC excludes durable medical equipment and medical supplies that are provided to the PMDC beneficiary as specified in the Medical Supplier Manual at N.J.A.C. 10:59.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 6 - FINANCIAL REPORTING › Section 10:60A-6.1 - Cost report preparation and timing of submission

Current through Register Vol. 56, No. 14, July 15, 2024
(a) PMDC facility staff shall submit a completed cost report in the form at chapter Appendix B, incorporated herein by reference, covering a period of one calendar year, commencing January 1 and ending December 31, to the Department on or before March 31 of the year next succeeding the calendar year for which the cost report is prepared.
1. The form of cost report is available for download from the DMAHS fiscal agent's website:
www.njmmis.com
and is available on request by calling the Provider Services Hotline at 1-800-776-6334.
2. The PMDC facility administrator and a corporate officer of the PMDC facility shall sign and certify the cost report.
i. If the cost report is prepared by someone other than the administrator or corporate officer of the PMDC facility, the preparer also shall sign and certify the cost report.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 6 - FINANCIAL REPORTING › Section 10:60A-6.2 - Financial statements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A PMDC facility shall complete and provide audited financial statements covering a period of one calendar year to the Department no later than March 31 of the year next succeeding the calendar year for which the financial statement is prepared by the PMDC facility.
1. The reporting period covered by a PMDC facility's audited financial statements shall be 12 consecutive calendar months commencing January 1 and ending December 31.
2. If the Department does not receive a PMDC facility's audited financial statements by March 31 of the calendar year next succeeding the calendar year for which the audited financial statements are prepared, the Department shall send the PMDC facility a notice, by certified mail, return receipt requested, advising the PMDC facility that its failure to timely submit acceptable audited financial statements shall result in a suspension of payment of any inflation adjustment factor over the base rate in effect on that March 31.
i. The Department shall not implement an inflation adjustment factor until the first day of the month following submission by the PMDC facility of its audited financial statements to the Department, in a form acceptable to the Department.
3. The Department shall review the audited financial statements as filed by the PMDC facility.
i. The Department may contact PMDC facility staff, either by writing or telephonically, to request additional information from PMDC facility staff if the audited financial statements are incomplete or do not otherwise conform to the requirements of this section.
ii. If PMDC facility staff fails to provide such additional information to the Department, the audited financial statements shall be deemed by the Department as not filed until audited financial statements are filed with and accepted by the Department.
iii. The Department shall provide written notice to the Administrator that an acceptable form of the audited financial statements have not been filed and that the Department shall suspend payment of any inflation adjustment factor over the then effective base rate for the month that the notice is so provided and until the first day of the month following submission by the PMDC facility of audited financial statements to the Department, in a form acceptable to the Department.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 6 - FINANCIAL REPORTING › Section 10:60A-6.3 - Audit

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department, subject to providing prior notice to the PMDC facility, may perform an on-site review at the Department's discretion of all financial information and statistics maintained by the PMDC facility to verify consistent reporting of data and/or extraordinary variations in data relating to the development of cost reports and/or financial statements by the PMDC facility.
1. Upon completion of an audit, the Department shall review its draft findings and adjustments with the PMDC facility staff and shall issue a written summary of such findings.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
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New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:61-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
This chapter outlines the policies and procedures for
				  coverage of clinical laboratory services that must be met in order to qualify
				  for reimbursement under the Medicaid/NJ FamilyCare fee-for-service programs.
				  The services of a qualified clinical laboratory for which reimbursement may be
				  made relate only to diagnostic tests performed in a laboratory which is
				  independent of a physician's office, a participating hospital, or other
				  facility. Rules for laboratory services provided by other types of providers
				  are included in the Medicaid/NJ FamilyCare rules for those particular
				  providers. Diagnostic laboratory tests, for purposes of this chapter, do not
				  include diagnostic radiological studies.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:61-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter,
				  shall have the following meanings, unless the context clearly indicates
				  otherwise:
"Automated multichannel tests" means laboratory tests which
				  can be and are frequently performed as groups and combinations (profiles) on
				  automated multichannel equipment.
"CLIA" means the Clinical Laboratory Improvement Amendments
				  of 1988, which extends the scope of Federal governmental regulation of
				  laboratories to all laboratory sites where laboratory tests are performed,
				  including physicians' offices. The purpose of this legislation is to uniformly
				  ensure the quality and reliability of medical tests performed by all
				  laboratories that test human specimens.
"CLIA Identification Number" means a 10 digit identification
				  number issued by the Centers for Medicare & Medicaid Services (CMS) to
				  independent clinical laboratories and other entities which perform laboratory
				  testing. A CLIA Identification Number must be on file with the New Jersey
				  Medicaid/NJ FamilyCare program before payment is made for any laboratory
				  testing.
"Clinical laboratory services" means professional and
				  technical laboratory services provided by an independent clinical laboratory
				  when ordered by a physician or other licensed practitioner of the healing arts
				  within the scope of his or her practice as defined by the laws of the state in
				  which he or she practices.
"Panel" means laboratory tests that are associated with
				  organ or disease oriented areas, such as organ "panels" (for example, hepatic
				  function panel). The tests listed with each panel identify the defined
				  components of that panel.
"Profile" means a combination of laboratory tests that can
				  be and are frequently done as groups and in combinations on automated
				  multi-channel equipment (for example, SMA6, SMA).
"Reference laboratory" means a laboratory meeting the
				  requirements stipulated in
				  10:61-1.4 which performs specific
				  tests at the request of another approved certified laboratory.
"Service laboratory" means a laboratory meeting the
				  requirements stipulated in
				  10:61-1.4 which performs specific
				  tests on the laboratory's own premises.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:61-1.3 - Scope of services

Current through Register Vol. 56, No. 14, July 15, 2024
Each laboratory shall provide the New Jersey Health Services
				  Program, Office of Utilization Management, Mail Code #33, PO Box 712, Trenton,
				  New Jersey 08625-0712, with a listing of tests, including panels and profiles
				  actually performed on its premises (address to be identified) and a current lab
				  price list, including discounts, with an update of said list on a semiannual
				  basis; beginning with the first listing due six months from the date of the
				  last report filed by providers enrolled as of January 17, 2006.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:61-1.4 - Requirements for provider participation; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To
				qualify for participation as a clinical laboratory under the Medicaid/NJ
				FamilyCare program, the following requirements must be met:
1. Licensure and/or approval by the New
				Jersey State Department of Health or comparable agency in the state in which
				the facility is located. This includes meeting certificate of need and
				licensure requirements, when required, and all applicable laboratory provisions
				of the New Jersey State Sanitary Code (see N.J.A.C. 8:45);
2. Enrollment as an independent laboratory
				under the Title XVIII Medicare program (see
				42 CFR 493.1
				);
3. Meet the requirements of an
				independent clinical laboratory under the Clinical Laboratory Improvement
				Amendments of 1988 (CLIA) (see
				42 USC
				1396(a)(9) ). (See
				10:61-2.1(a)5.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:61-1.5 - Medicare-Medicaid relationship

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon approval
				as an independent laboratory provider for Title XIX Medicaid participation and
				reimbursement, the requirements for independent laboratory services under the
				Title XVIII Medicare program shall be followed.
(b) A laboratory approved for Medicaid/NJ
				FamilyCare participation shall only provide services and be reimbursed for the
				specialties and subspecialties specifically approved for Medicare
				participation.
(c) State, county
				and municipal laboratories located in New Jersey may qualify for Medicaid/NJ
				FamilyCare reimbursement provided they meet the criteria in
				10:61-1.4 and 1.5.
(d) Any entity that performs diagnostic tests
				in connection with its provider practice shall comply with this chapter and
				shall have a CLIA Identification Number to perform clinical laboratory testing
				reimbursable by the Medicaid/NJ FamilyCare program. A CLIA Identification
				Number must be on file with the Medicaid/NJ FamilyCare program before payment
				is made for any laboratory testing.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:61-1.6 - Orders for laboratory tests; recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All orders for
				clinical laboratory services shall be in the form of an explicit order
				personally signed by the physician or other licensed practitioner requesting
				the services, or be in an alternative form of order specifically authorized in
				(b)1 through 3 below. The written order shall contain the specific clinical
				laboratory test(s) requested, shall be on file with the billing laboratory and
				shall be available for review by Medicaid/NJ FamilyCare representatives upon
				request.
(b) If a signed order is
				not utilized, then clinical laboratory services shall be ordered in one of the
				following ways:
1. In the absence of a
				written order, the patient's chart or medical record may be used as the test
				requisition or authorization, but must be physically present at the laboratory
				at the time of testing and available to Federal or State representatives upon
				request;
2. A test request also may
				be submitted to the laboratory electronically, if the system used to generate
				and transmit the electronic order has adequate security and system safeguards
				to prevent and detect fraud and abuse and to protect patient confidentiality.
				The system shall be designed to prevent and detect unauthorized access and
				modification or manipulation of records, and shall include, at a minimum,
				electronic encryption; or
3.
				Telephoned or other oral laboratory orders are also permissible, but shall be
				followed up with a written or electronic request within 30 days of the
				telephone or other oral request, which shall be maintained on file with the
				clinical laboratory. If the laboratory is unable to obtain the written or
				electronic request, it must maintain documentation of its efforts to obtain
				them.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:61-1.7 - Basis of reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
Reimbursement shall be on the basis of the lowest
				  professional charge, not to exceed an allowance determined reasonable by the
				  Commissioner of Human Services, and further limited by Federal policy relative
				  to payment of clinical laboratory services. The maximum fee schedule
				  (allowance) is set forth at N.J.A.C. 10:61-3. In no event shall the charge to
				  the Medicaid/NJ FamilyCare program exceed the provider's charge for identical
				  services to other groups or individuals.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 2 - PROVISION OF SERVICE › Section 10:61-2.1 - Clinical Laboratory Improvement Amendments (CLIA) requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All independent
				clinical laboratories and other entities providing clinical laboratory services
				to Medicaid/NJ FamilyCare beneficiaries must meet the requirements of the
				Clinical Laboratory Improvement Amendments (CLIA) of 1988. These requirements
				include that the provider must have one of the following:
1. A certificate of waiver;
2. A certificate of compliance;
3. A registration certificate;
4. A certificate for provider-performed
				microscopy (PPM) procedures;
5. A
				certificate of accreditation, and a registration certificate or a certificate
				of compliance; or
6. Be deemed CLIA
				exempt due to accreditation by a private, nonprofit accreditation organization
				or exempted under an approved state laboratory program. (See code of Federal
				Regulations 42 CFR 493 )
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 2 - PROVISION OF SERVICE › Section 10:61-2.2 - Specific services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The sum of any
				number of the components of a battery of tests shall not exceed the total
				charged for the group offering (panel or profile), whether done by automation
				or bench testing, whether or not the equipment is available in the facility. A
				battery of tests is considered to be those components of a panel or series of
				tests which, when combined, mathematically or otherwise, comprise a finished
				identifiable laboratory study or studies. Examples are:
1. The components of a metabolic profile or
				other automated laboratory study;
2. An MCH, MCV, or other test, as a component
				of a C.B.C.;
3. Inclusive of all
				ova and parasites in a stool examination.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 2 - PROVISION OF SERVICE › Section 10:61-2.3 - Limitations on laboratory services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Tests performed
				by a non-approved laboratory are not reimbursable. The referring laboratory
				shall verify approved status.
(b)
				Additional payment will not be made to a laboratory for obtaining specimens,
				except when performed in a long-term care facility, boarding home, or
				home.
(c) A laboratory shall be
				reimbursed only those tests that are within the specialty/subspecialty
				categories indicated in its CLIA approval.
(d) Laboratory services provided primarily
				for the diagnosis or treatment of infertility shall not be covered by the
				Medicaid/NJ FamilyCare program.
1. For those
				HCPCS procedure codes which are determined to be primarily for the diagnosis of
				infertility, refer to the HCPCS subchapter and the Indicator "F."
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 2 - PROVISION OF SERVICE › Section 10:61-2.4 - Laboratory rebates

Current through Register Vol. 56, No. 14, July 15, 2024
Rebates by reference laboratories, service laboratories,
				  physicians or other utilizers or providers of laboratory service are prohibited
				  under the Medicaid/NJ FamilyCare program. Rebates shall include refunds,
				  discounts or kickbacks, whether in the form of money, supplies, equipment, or
				  other things of value. Laboratories shall not rent space or provide personnel
				  or other considerations to a physician or other practitioner, whether or not a
				  rebate is involved.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:61-3.1 - Purpose, scope and general provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Medicaid/NJ
				FamilyCare program uses the Centers for Medicare & Medicaid Services (CMS)
				Healthcare Common Procedure Coding System (HCPCS), 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 the
				American Medical Association (AMA) Current Procedural Terminology (CPT) codes
				published by PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010. The
				HCPCS and CPT codes are incorporated herein by reference, as amended and
				supplemented. AMA and CMS revisions to the CPT codes and the Healthcare Common
				Procedure Coding System (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 and new
				reimbursement amounts codes specified by the Department and specification of
				new reimbursement amounts for new codes will be made through rulemaking in
				accordance with the Administrative Procedure Act,
				52:14B-1 et seq. HCPCS follows the
				American Medical Association's Physicians' Current Procedural Terminology (CPT)
				(American Medical Association, P.O. Box 10950, Chicago, IL 60610.)
				architecture, employing a five-position code and as many as two two-position
				modifiers. Unlike the CPT numeric design, the CMS-assigned codes and modifiers
				contain alphabetic characters.
(b)
				HCPCS has been developed as a three-level coding system. The CPT procedure
				narratives for Level I codes are incorporated herein by reference.
1. Level 1 codes (Narratives found in CPT).
				CPT is a listing of descriptive terms and numeric identifying codes and
				modifiers for reporting medical services and procedures performed by
				physicians. (See
				10:61-3.2.)
2. Level II codes are assigned by CMS for
				physician and non-physician services which are not in CPT. (See
				10:61-3.3.)
3. Level III codes identify services unique
				to the Medicaid/NJ FamilyCare program. These codes are assigned by the Division
				to be used for those services not identified by CPT codes or CMS-assigned
				codes. (See
				10:61-3.4.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:61-3.2 - HCPCS procedure codes and maximum fee allowance schedule for Level 1

Current through Register Vol. 56, No. 14, July 15, 2024
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New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:61-3.3 - HCPCS procedure codes, procedure description and maximum fee allowance schedule for Level 2

Current through Register Vol. 56, No. 14, July 15, 2024
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New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:61-3.4 - HCPCS procedure codes, procedure description and maximum fee allowance schedule for Level 3

Current through Register Vol. 56, No. 14, July 15, 2024
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New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 61 - INDEPENDENT CLINICAL LABORATORIES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Appendix - Appendix

Current through Register Vol. 56, No. 14, July 15, 2024
Fiscal Agent Billing Supplement
AGENCY NOTE: The Fiscal Agent Billing Supplement is appended
				  as a part of this chapter but is not reproduced in the New Jersey
				  Administrative Code. When revisions are made to the Fiscal Agent Billing
				  Supplement, replacement pages will be distributed to providers, and copies will
				  be filed with the Office of Administrative Law. For a copy of the Fiscal Agent
				  Billing Supplement, access
www.njmmis.com
or write to:
Gainwell Technologies
PO Box 4801
Trenton, New Jersey 08650-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, New Jersey 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter delineates the New Jersey Medicaid/NJ
				  FamilyCare fee-for-service programs' standards for examinations and care for
				  vision defects and/or eye diseases for the purpose of maintaining or improving
				  the health of New Jersey Medicaid/NJ FamilyCare fee-for-service
				  beneficiaries.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter,
				  shall have the following meanings unless the context clearly indicates
				  otherwise:
"Clinical laboratory services" means professional and
				  technical laboratory services performed by a clinical laboratory certified by
				  CMS in accordance with the Federal Clinical Laboratory Improvement Act (CLIA),
				  42 U.S.C. §
										263a and ordered by a physician or other
				  licensed practitioner, within the scope of his or her practice, as defined by
				  the laws of the State of New Jersey and/or of the state in which the
				  practitioner practices.
"CMS" means the Federal Centers for Medicare and Medicaid
				  Services.
"Low vision" means reduced visual acuity and/or abnormal
				  visual fields from a disorder in the visual system.
"Low vision client" means an individual with an eye disorder,
				  which reduces visual performance and cannot be corrected by conventional
				  methods.
"Low vision follow-up examination" means examinations
				  provided to clients with aids, to monitor progress and problems.
"Low vision service" means a series of comprehensive tests,
				  evaluations, and multidisciplinary referrals provided for the low vision
				  patient, which has as its objective a prescription of low vision aids and
				  instruction/training programs to enhance the low vision patient's
				  performance.
"Ophthalmologist" means a fully licensed medical doctor who
				  has been recognized by the New Jersey Medicaid/NJ FamilyCare fee-for-service
				  programs as a specialist in ophthalmology.
"Optometrist" means any person who is licensed by the New
				  Jersey State Board of Optometry to engage in the practice of optometry, or
				  licensed to engage in the practice of optometry in the state in which he or she
				  performs such functions.
"Practitioner" means a licensed ophthalmologist or
				  optometrist, acting within the scope of licensure.
"Transfer" means the relinquishing of responsibility for the
				  continuing care of the beneficiary by one practitioner and the assumption of
				  such responsibility by another practitioner.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.3 - Providers of professional services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Within the
				restrictions of their respective licensure, the following are eligible
				providers of eye care upon fulfilling the Enrollment Process requirements in
				N.J.A.C.
				10:49-3.2:
1. Ophthalmologists or optometrists licensed
				in the State of New Jersey;
2.
				Ophthalmologists or optometrists in another state who are duly licensed in that
				state;
3. Independent clinics
				approved by the New Jersey Medicaid/NJ FamilyCare fee-for-service programs to
				render eye care services; and
4.
				Hospitals meeting the definition of "hospital" at
				N.J.A.C.
				10:52-1.2.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.4 - Covered services

Current through Register Vol. 56, No. 14, July 15, 2024
Professional services include office visits for evaluation
				  and management, comprehensive eye examinations, low vision examinations, low
				  vision work-ups, vision training work-ups, vision training program visits as
				  well as other specific procedures as listed at
				  N.J.A.C.
				  10:62-3.2. Payment is made subject to the
				  limitations specified under each type of service. In order to determine whether
				  a service requires prior authorization, and for details regarding such prior
				  authorization of services, see
				  N.J.A.C.
				  10:62-1.16.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.5 - Comprehensive eye examination

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A comprehensive
				eye examination may include cycloplegics and a post cycloplegic visit. All
				findings and data, including positive and negative, shall be clearly recorded.
				A comprehensive eye examination shall include the following, as a minimum,
				where possible unless contraindicated:
1.
				Detailed case history;
2. Complete
				visual acuity findings;
3. External
				and internal (ophthalmoscopic) examination including slit lamp;
4. Refraction, objective and
				subjective;
5. Extra-ocular
				measurement;
6. Gross visual
				fields, central and peripheral;
7.
				Tonometry when indicated for patients under 35; tonometry is mandatory for all
				patients over 35. The specific method used should be identified and recorded;
				the finger palpation test is not acceptable;
8. Binocular coordination testing (distance
				and near), fusion, steropsis, and color vision;
9. The diagnosis, including, but not limited
				to, ocular deficiency or deformity, visual or muscular anomaly; and
10. Recommendations.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.7 - Low vision work-up

Current through Register Vol. 56, No. 14, July 15, 2024
For purposes of the New Jersey Medicaid/NJ FamilyCare
				  fee-for-service programs, a low vision work-up consists of certain testing
				  techniques and procedures to determine what optical aids and devices can be
				  prescribed for an individual to increase range of vision. A low vision work-up
				  requires a written report and is much more detailed than the low vision
				  examination that follows a complete comprehensive
				  examination.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.8 - Vision training program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For purposes of
				the New Jersey Medicaid/NJ FamilyCare fee-for-service programs, vision training
				is the use of certain procedures and modalities for the development of and/or
				increase in the vision capacity of the eye(s) with poor and/or inconsistent or
				distorted vision localization.
(b)
				Vision training is limited to orthoptics, with its acceptable procedures and/or
				modalities, and further limited to the following types of conditions to be
				treated by private physicians approved for such training by the respective peer
				group:
1. Strabismus;
2. Amblyopia;
3. Heterophoria; and
4. Accommodative and/or convergence
				anomalies.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.9 - Office visits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HCPCS 99201, 99202, 99203, 99204, 99205,
				99301, 99302, 99303, 99321, 99322 and 99323 are not reimbursable with 92002,
				92004, 92012 or 92014 on the same day.
(b) When multiple special ophthalmological
				services or ophthalmoscopic services are billed on the same day for the same
				patient in an office setting, reimbursement shall be limited to the highest
				valued procedure.
(c) When the
				setting for the initial visit is an office or residential health care facility,
				for reimbursement purposes it is limited to a single visit. Future use of this
				category of codes shall be denied when the beneficiary is seen by the same
				physician, group of physicians, or shared health care facility as defined at
				N.J.A.C.
				10:49-4.1.
(d) Reimbursement for an initial office visit
				also precludes subsequent reimbursement for an initial residential health care
				facility visit and vice versa.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.11 - Emergency room visits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When a
				physician sees the patient in the emergency room instead of the practitioner's
				office, the physician shall use the same HCPCS for the visit that would have
				been used if seen in the physician's office: 99211, 99212, 99213, 99214 or
				99215 only. Records of that visit shall become part of the notes in the office
				chart.
(b) When patients are seen
				by hospital-based emergency room physicians who are eligible to bill the New
				Jersey Medicaid/NJ FamilyCare fee-for-service programs, then the appropriate
				HCPCS shall be used. The "Visit" codes are limited to 99281, 99282, 99283,
				99284, and 99285.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.12 - Inpatient hospital services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To qualify as
				documentation that the service was rendered by the practitioner during an
				inpatient stay, the beneficiary's medical record must contain the
				practitioner's notes indicating that the practitioner personally:
1. Reviewed the beneficiary's medical history
				with the beneficiary and/or his or her family, depending upon the medical
				situation;
2. Performed an eye
				examination, or other procedure;
3.
				Established, confirmed or revised the diagnosis; and
4. Visited and examined the beneficiary on
				each date of service for which a claim for reimbursement is made.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.13 - Consultations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A consultation shall be eligible for
				reimbursement only when the consultation has been performed by a specialist
				recognized as such by the Medicaid/NJ FamilyCare programs, the request has been
				made by or through the patient's attending physician, and the need for such a
				request would be consistent with good medical practice. Two types of
				consultation shall be eligible for reimbursement: comprehensive consultation
				and limited consultation.
(b) In
				order to receive reimbursement for the HCPCS for an office consultation (99244,
				99245) or a confirmatory consultation (99274 and 99275), the provider shall
				perform a total systems evaluation by history and physical examination,
				including a total systems review and total systems physical examination, or,
				alternatively, utilize one or more hours of the consulting physician's personal
				time in the performance of the consultation.
(c) In addition to the recordkeeping
				requirements of
				N.J.A.C.
				10:62-1.21, reimbursement for HCPCS 99244,
				99245, 99274, and 99275, related to the provision of a comprehensive
				consultation, requires that the applicable statements listed below, or language
				essentially similar to those statements, be inserted in the "remarks" section
				of the claim form. The claim form shall be signed by the provider who performed
				the consultation.
1. Examples:
i. I personally performed a total (all)
				systems evaluation by history and physical examination; or
ii. This consultation utilized 60 or more
				minutes of my personal time.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.14 - Home services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The home visit HCPCS 99343 and 99353
				shall not apply to residential health care facility or nursing facility
				settings. These HCPCS refer to a physician visit limited to the provision of
				medical care to an individual who would be too ill to go to a physician's
				office and/or is "home bound" due to his or her physical condition. When
				billing for a second or subsequent patient treated during the same visit, the
				visit shall be billed as a home visit.
(b) For purposes of New Jersey Medicaid/NJ
				FamilyCare fee-for-service reimbursement, HCPCS 99341, 99342, 99351, and 99352
				apply when the provider visits a New Jersey Medicaid/NJ FamilyCare fee-for-
				service beneficiary in the home setting and the visit does not meet the
				criteria specified for a home visit in (a) above.
(c) In addition to the recordkeeping
				requirements indicated in
				N.J.A.C.
				10:62-1.21, the record and documentation of a
				home visit shall become part of the office progress notes and shall include, as
				appropriate, the following information:
1.
				The purpose of the visit;
2. The
				pertinent history obtained;
3.
				Pertinent physical findings, including pertinent negative physical findings
				based on (c)1 and 2 above;
4. The
				procedures, if any performed, with results;
5. Lab, X-ray ECG, etc., ordered with
				results; and
6. A diagnosis(es)
				plus treatment plan status relative to present or pre-existing illness(es) plus
				pertinent recommendations and actions.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.15 - Unusual travel and escort services

Current through Register Vol. 56, No. 14, July 15, 2024
HCPCS 99082 may be used for travel costs only associated and
				  billed with Home Visit. (See codes 99341, 99342 and 99343.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.16 - Professional services requiring prior authorization

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Form FD-358 (Request for Prior Authorization for Vision Care Services) shall be
				used to request prior authorization for professional services. Instructions for
				completing the form are provided in the Fiscal Agent Billing Supplement. The
				completed form, clearly indicating the reasons for requesting the service
				requiring prior authorization, shall be submitted to the Vision Care Unit,
				Division of Medical Assistance and Health Services, Mail Code # 16, PO Box 712,
				Trenton, New Jersey 08625-0712. When a request for prior authorization is
				approved or denied, the provider shall receive a letter of notification from
				the fiscal agent.
(b) Items
				requiring prior authorization should not be provided to the New Jersey
				Medicaid/NJ FamilyCare fee-for-service beneficiary until the authorization is
				received by the provider from the fiscal agent.
(c) The following professional services
				require prior authorization:
1. Low vision
				work-up;
2. Vision training
				program;
3. Vision training
				work-up; and
4. All other services
				not specified as a covered service under
				10:62-1.4.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.17 - Prescription policies

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon request, a
				beneficiary must be provided with his or her prescription for an optical
				appliance. The following information shall be indicated on the prescription:
				name, address, New Jersey Medicaid/NJ FamilyCare fee-for-service Identification
				Number, date of examination, and diagnosis code(s).
(b) If a beneficiary requests a duplicate
				prescription, the duplicate prescription shall clearly indicate: "THIS IS A
				DUPLICATE." The date of the original prescription shall also be included. The
				dispensing provider shall retain the original prescription.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.18 - Prescribing medications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All covered
				pharmaceutical services provided by licensed professionals of vision care
				services under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs
				shall be prescribed in accordance with the scope of their practice.
(b) The Pharmaceutical Services manual,
				N.J.A.C. 10:51, sets forth the provisions for covered and noncovered
				pharmaceutical services, prior authorization, quantity of medication,
				administration of drugs, pharmaceutical dosage and directions,
				telephone-rendered original prescriptions, changes or additions to the original
				prescription, non-proprietary or generic dispensing, and prescription
				refill.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.19 - Clinical laboratory services

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				(Reserved)
(b) Clinical laboratory
				services are furnished by clinical laboratories and by physician office
				laboratories (POLs) that meet the CMS regulations pertaining to clinical
				laboratory services defined in the Clinical Laboratory Improvement Amendments
				(CLIA) of 1988, section 1902(a)(9) of the Social Security Act,
				42 U.S.C. §
										1396a(a)(9), and as
				indicated at
				N.J.A.C.
				10:61-1.2, the New Jersey Medicaid/NJ
				FamilyCare fee-for-service programs' Independent Clinical Laboratory Services
				manual and N.J.A.C. 8:44 and 8:45.
(c) All independent clinical laboratories and
				other entities performing clinical laboratory testing shall possess
				certification as required by CLIA 1988, and the New Jersey Department of Health
				rules found in N.J.A.C. 8:44 and 8:45.
(d) An ophthalmologist may claim
				reimbursement for clinical laboratory services performed for the practitioner's
				own patients within the practitioner's office, subject to the following:
1. An ophthalmologist shall meet the
				conditions of the CLIA regulations before he or she may perform clinical
				laboratory testing for New Jersey Medicaid/NJ FamilyCare fee-for-service
				beneficiaries; and
2. The clinical
				laboratory tests shall be standard clinical laboratory procedures consistent
				with the ophthalmologist's CLIA certification, certificate of waiver or
				certificate of registration as an independent clinical laboratory.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.20 - Personal contribution to care requirements for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D

Current through Register Vol. 56, No. 14, July 15, 2024
(a) General
				policies regarding the collection of personal contribution to care for NJ
				FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D services are set
				forth at N.J.A.C. 10:49-9.
(b)
				Personal contribution to care for NJ FamilyCare-Plan C services is $ 5.00 per
				visit for office visits, except when the service is provided for preventive
				care.
1. An office visit is defined as a
				face-to-face contact with a vision care professional that meets the
				documentation requirements in this subchapter and N.J.A.C. 10:62-3.
2. Office visits include eye care
				professional services provided in the office, patient's home, or any other
				site, excluding hospital, where the child may have been examined by the vision
				care professional. Generally, these procedure codes are set forth in
				N.J.A.C.
				10:62-3.2.