New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 4 - CENTERS FOR MEDICARE & MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:58A-4.5 - HCPCS procedure codes-qualifiers

Current through Register Vol. 56, No. 14, July 15, 2024
HCPCS CODES
MOD
DESCRIPTIONS
(a) Surgical Services
11975 SA
QUALIFIER: Reimbursed for the
insertion or reinsertion of
implantable contraceptive capsules
and the post insertion visit when the
APN bills for the service.
11976 SA
QUALIFIER: The maximum fee
allowance is reimbursed for the
removal of implantable contraceptive
capsules and for the post removal
visit.
11977 SA
QUALIFIER: The maximum fee
allowance is reimbursed for the
removal and reinsertion of
implantable contraceptive capsules
and for the post-removal/reinsertion
visit.
HCPCS CODES
MOD
DESCRIPTIONS
E 29105 SA, E 29125 SA, E 29130 SA, E 29200 SA, E 29220 SA, E 29240 SA,
QUALIFIER: These
E 29260 SA, E 29280 SA, E 29505 SA, E 29515 SA, E 29520 SA, E 29530 SA, E
HCPCS are excluded
29540 SA, E 29550 SA, E 29580 SA, E 29590 SA, E 29700 SA, E 29705 SA, E 29710
from multiple
SA, E 29715 SA, E 29720 SA, E 29730 SA, E 29740 SA, E 31720 SA, E 36415 SA, E
surgical pricing and
57150 SA, E 58300 SA, E 58301 SA, E 59025 SA, E 59430 SA
as such shall be
reimbursed like the
primary procedure at
100 percent of the
program maximum fee
allowance even when
the procedure is
performed on the
same beneficiary, by
the same provider,
at the same session.
(b) Laboratory services:
36415 SA
QUALIFIER: Once per visit, per
patient
(c) Immunizations:
N 90746
QUALIFIER: This applies only to
high risk beneficiaries over 19 years
of age.
90465, 90466,
QUALIFIER: These codes apply only
90467, 90468, 90471,
to the administration of vaccines to
90472, 90473, 90474
beneficiaries under 19 years of age
who qualify for the Vaccine for
Children (VFC) program. See N.J.A.C.
10:58A-2.13 and 4.2(k).
(d) Infusion therapy (excluding allergy, immunizations and chemotherapy):
96360 SA
QUALIFIER: Not to be used for
routine IV drug injection or
infusion.
96361 SA
QUALIFIER: Not to be used for
routine IV drug injection or
infusion.
(e) Therapeutic or diagnostic injections:
There are no qualifiers for therapeutic or diagnostic injections.
(f) Mental health services:
QUALIFIER: Only under exceptional circumstances
will more than one mental health procedure be reimbursed
per day for the same beneficiary by the same APN, group
of APNs shared health facility, or providers sharing a
common record. When circumstances require more than one
mental health procedure, the medical necessity for the
services shall be documented in the patient's chart.
HCPCS CODES
MOD
DESCRIPTIONS
90801 SA
24.70
QUALIFIER: This code requires for reimbursement
purposes a minimum of 50 minutes of direct personal
clinical involvement with the patient or family member.
90804 SA
Individual
12.40
Psychotherapy-- 25
minute session
QUALIFIER: This code requires for reimbursement
purposes a minimum of 25 minutes of direct personal
clinical involvement with the patient or family member.
90805 SA
QUALIFIER: This code requires
for reimbursement purposes a minimum
of 25 minutes direct personal clinical
involvement with the patient or
family, including medicine evaluation
and management services.
90806 SA
Individual
24.70
Psychotherapy--50
minute session
QUALIFIER: This code requires
for reimbursement purposes a minimum
of 50 minutes of direct personal
clinical involvement with the patient
or family member.
90807 SA
24.70
QUALIFIER: This code requires for reimbursement
purposes a minimum of 50 minutes direct personal clinical
involvement with the patient or family, including
medicine evaluation and management services.
90847 SA
Family Therapy--50
24.70
minute session
QUALIFIER: This code requires, for reimbursement
purposes, a minimum of 50 minutes of direct personal
clinical involvement with the patient or family member.
90847 SA 22
Family Therapy--80
30.40
minute session
QUALIFIER: This code requires, for reimbursement
purposes, a minimum of 80 minutes of direct personal
clinical involvement with the patient or family member.
90887 SA
Family
12.40
Conference--25 minute
session
QUALIFIER: This code requires, for reimbursement
purposes, a minimum of 25 minutes of direct personal
clinical involvement with the patient or family member.
The CPT narrative otherwise remains applicable.
(g) Evaluation and management services:
1. Office or other outpatient services: new patient
99201 SA, 99202 SA
99203 SA, 99204 SA
i. QUALIFIER: An initial office visit, or an initial residential health care visit, is limited to a single visit. Future use of this category of codes will be denied when the beneficiary is seen by the same clinical practitioner, group of clinical practitioners, or member of the same shared health care facility.
ii. QUALIFIER: HCPCS procedure codes 99201 SA and 99202 SA are exceptions to the requirements outlined in the qualifier for the initial visit. For the codes 99201 SA and 99202 SA, the provider is expected to follow the qualifier applied to routine visit or follow-up care visit for reimbursement purposes.
iii. QUALIFIER: As described at 10:58A-1.4, Evaluation and Management services pertain to patients presenting with symptoms, and as such, exclude Preventive Health Care. Preventive services for patients including newborns through persons 20 years of age are billed under EPSDT, when the procedure requirements are met, as described at 10:58A-2.11.
99221 SA
Hospital inpatient services: initial
hospital care
99301 SA, 99302 SA, 99303 SA,
Nursing facility services, initial
99321 SA, 99322 SA
care, new or established patient
Domiciliary or rest home services: new
patient
99341 SA, 99342 SA, 99343 SA,
Home visit: new patient
99344 SA, 99345 SA
iv. QUALIFIER: When reference is made in the CPT manual to the procedures listed above, the intent of the Medicaid and NJ FamilyCare fee-for-service programs is to consider this service as the Initial Visit.
v. QUALIFIER: Reimbursement for an initial office visit or initial residential health care facility visit will be disallowed, if a preventive medicine service, EPSDT examination or office consultation were billed within a twelve month period by a clinical practitioner, group, shared health care facility, or clinical practitioners sharing a common record.
vi. QUALIFIER: In reference to a nursing facility or hospital, the Initial Visit concept will still apply for reimbursement purposes. Subsequent readmissions to the same facility may be reimbursed as Initial Visits, if the readmission occurs more than 30 days from a previous discharge from the same facility by the same provider. When the readmission occurs within 30 days from a previous discharge, the provider shall bill the relevant HCPCS procedure codes specified under the headings Subsequent Hospital Care or Subsequent Nursing Facility Care.
vii. QUALIFIER: Initial Hospital Visit during a single admission will be disallowed to the same clinical practitioner, group, shared health care facility, or clinical practitioners sharing a common record who submit a claim for a consultation and transfer the patient to their service.