reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.9 - Minimum documentation; home visits and house calls

Current through Register Vol. 56, No. 14, July 15, 2024
For HOME VISIT and HOUSE CALL codes, in addition to the components listed in 10:54-2.8, the office progress notes shall include 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 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.10 - Minimum documentation; hospital or nursing facility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In a hospital or nursing facility, documentation shall include:
1. An update of symptoms;
2. An update of physical findings;
3. A resume of findings of procedures, if any are applicable;
4. The pertinent positive and negative findings of laboratory, X-Ray, electrocardiograms (ECGs), or other tests or consultations;
5. Any additional planned studies, if any, including the reasons for any studies; and
6. Treatment changes, if any.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.11 - Minimum documentation; hospital discharge medical summary

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When an inpatient is discharged from the hospital to the care of another medical facility (such as a nursing facility or a community home care agency), a legible discharge and medical summary shall be prepared and signed by the attending physician.
(b) The summary should cover the pertinent findings of the history, physical examination, diagnostic and therapeutic modalities, consultations, plan of care or therapy, medications, recommendations for follow-up care and final diagnosis related to the patient's hospitalization. Recommendations should also be made for further medical care and should be forwarded to the institution or agency to which the patient has been referred.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.12 - Minimum documentation; mental health services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For each patient contact made by a physician for psychiatric therapy, written documentation shall be developed and maintained to support each medical or remedial therapy, service, activity, or session for which billing is made. The documentation, at a minimum, shall consist of the following:
1. The specific services rendered and modality used, for example, individual, group, and/or family therapy;
2. The date and the time services were rendered;
3. The duration of services provided, for example, one hour, or one-half hour;
4. The signature of the physician who rendered the service;
5. The setting in which services were rendered;
6. A notation of impediments, unusual occurrences or significant deviations from the treatment described in the Plan of Care;
7. Notations of progress, impediments, treatment, or complications; and
8. Other relevant information, which may include dates or information not included in above, yet important to the clinical picture and prognosis.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 3 - PROVISION OF SERVICES › Section 10:54-3.1 - Medical Justification Program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Medical Justification Program of the New Jersey Medicaid/NJ FamilyCare program defines certain surgical and diagnostic procedures that are reimbursable only when acceptable written justification by the physician accompanies the claim form. The procedures that require medical justification are identified in the Centers for Medicare and Medicaid Services (CMS) Healthcare Common Procedures Coding System by the indicator "M" preceding the HCPCS code. (See N.J.A.C. 10:54-9.)
(b) Physicians shall maintain written records that substantiate the use of a given procedure code. These records shall be available for review and/or inspection if requested by the New Jersey Medicaid/NJ FamilyCare program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 3 - PROVISION OF SERVICES › Section 10:54-3.2 - Prior authorization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prior authorization, as used in this chapter, is the approval granted by the New Jersey Medicaid/NJ FamilyCare program before a service is rendered or an item provided. For additional information about prior and retroactive authorization, see also N.J.A.C. 10:49-6 and 10:54-5 and 7.
(b) Certain services require prior authorization, such as cosmetic surgery, certain psychiatric services and all out-of-State inpatient and outpatient hospital services, except in the conditions listed in (c) below. Services rendered to Medicaid/NJ FamilyCare program beneficiaries enrolled in a Health Maintenance Organization (HMO) may also require authorization by the Health Maintenance Organization (for details, see Managed Health Care Services in N.J.A.C. 10:74).
(c) Prior authorization shall not be required for the following:
1. Hospital covered services to any beneficiary who resides out-of-State at the discretion of the New Jersey Department of Human Services and who has a HSP (Medicaid) case number with either:
i. The first and second digits of 90; or
ii. The third and four digits of 60; or
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 3 - PROVISION OF SERVICES › Section 10:54-3.3 - Authorization of reimbursement for out-of-State hospital services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A request for authorization for reimbursement for out-of-State hospital services shall be directed to the Medical Assistance Customer Center (MACC) in the area where the beneficiary resides (see N.J.A.C. 10:49, Appendix), except that:
1. Prior authorization of out-of-State psychiatric services shall be directed to the Office of Utilization Management, Mental Health Services Unit, and shall comply with the requirements of 10:54-7.4.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 3 - PROVISION OF SERVICES › Section 10:54-3.4 - Out-of-State elective services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For a beneficiary residing in New Jersey in other than a hospital, who is to be admitted or referred to an out-of-State hospital or physician for elective inpatient or outpatient hospital services, the physician planning such action shall sign a statement that the medically necessary service is not available at a reasonable distance within the State of New Jersey and shall send the signed statement to the MACC.
(b) For a beneficiary traveling outside New Jersey who is to be admitted to an out-of-State hospital for elective surgery, as part of the prior authorization request, the attending physician shall justify the decision by sending to the Medical Assistance Customer Center (MACC), a signed statement that an attempt to return to a New Jersey hospital would create a significant risk to life or health or would create the need for an unreasonable amount of travel for the beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 3 - PROVISION OF SERVICES › Section 10:54-3.5 - Out-of-State emergencies and interstate transfers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prior authorization shall not be required for emergencies nor for interstate hospital transfers. However, in these instances, the hospital shall attach the attending physician's signed statement to the claim, attesting to the nature of the emergency; or, for a hospital interstate transfer, attesting to the unavailability of the medically necessary service within a reasonable distance within the State of New Jersey; or that the need to obtain prior authorization would result in a delay that could create a significant risk to life or health or unduly prolong hospitalization. The physician shall provide the hospital with a copy of the authorization letter to be attached to the claim from the hospital, when applicable.
(b) For prior authorization and preadmission screening for mental health and psychiatric services, see 10:54-7.1 and 7.4 of this Chapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.1 - General payment methodology

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Payment for physician services covered under the New Jersey Medicaid or NJ FamilyCare program is based upon the customary charge prevailing in the community for the same service but shall not exceed a "Maximum Fee Allowance Schedule" which has been determined reasonable by the Commissioner and set forth in N.J.A.C. 10:54-9 and as limited by Federal policy relative to the payment of physicians and other licensed health care practitioners.
1. In no event shall the charge to the New Jersey Medicaid or NJ FamilyCare program exceed the charge by the provider for identical services to other governmental agencies or other groups or individuals in the community.
2. Effective July 20, 1998, for services provided to beneficiaries eligible for both Medicare Part B and Medicaid or NJ FamilyCare, including Qualified Medicare Beneficiaries, Medicaid or NJ FamilyCare shall reimburse physicians and practitioners the Medicare Part B coinsurance and deductible amount or the Medicaid or NJ FamilyCare maximum fee allowable (less any third party payments, including Medicare reimbursement), whichever is less.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.2 - Personal contribution to care requirements for NJ FamilyCare-Children's Program-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-Children's Program-Plan C and copayments for NJ FamilyCare-Plan D are set forth at N.J.A.C. 10:49-9.
(b) Personal contribution to care for NJ FamilyCare-Children's Program-Plan C services is $5.00 a visit for office visits, except when the service is provided for preventive care, prenatal care, family planning services or substance abuse treatment services.
1. An office visit is defined as a face-to-face contact with a medical professional under the supervision of the physician, which meets the documentation requirements codified at 10:52-2.6 through 2.12.
2. Office visits include physician services provided in the office, patient's home, or any other site excluding hospital where the child may have been examined by the physician. Generally, these procedure codes are in the 90000 HCPCS series of reimbursable codes codified at 10:54-9.3.
3. Physician services which do not meet the requirements of an office visit as defined in this chapter, such as surgical services, immunizations, laboratory or x-ray services, do not require a personal contribution to care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.3 - Use of physician reimbursement codes

Current through Register Vol. 56, No. 14, July 15, 2024
When the examination of the beneficiary is by the same physician, a practitioner, a shared health facility or group of physicians/practitioners who share a common record, the examination is considered that of a single provider.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.4 - HCPCS codes for new patients visits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This rule applies to office, and hospital inpatient and outpatient services to new patients (excluding preventive health care for patients through 20 years of age).
(b) When the CPT manual refers to office or hospital inpatient or outpatient services-new patient, the Medicaid/NJ FamilyCare program will consider this service an initial visit.
1. When the setting for an initial visit is an office or residential health care facility, reimbursement shall be limited to a single visit. Future requests for reimbursement which include this category of codes will be denied when the beneficiary is seen by the same physician, practitioner, group of physicians/practitioners, or shared health care facility sharing a common record. Reimbursement for an initial office visit precludes subsequent reimbursement for an initial residential health care facility visit and vice versa.
2. 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 was billed within a twelve month period by a physician, group, shared health care facility, or practitioner sharing a common record.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.5 - Use of HCPCS codes for established patient visits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This rule applies to office, inpatient or outpatient services to established patients (excluding preventive health care for patients through 20 years of age).
(b) "Routine visit" or "follow-up visit" means the care and treatment by a physician, which includes those procedures ordinarily performed during a health care visit, which is dependent upon the setting and the physician's discipline. The setting may be an office, hospital, nursing facility or residential health care facility.
1. In order to receive reimbursement for a routine visit or follow-up visit, the documentation requirements set forth in 10:54-2.3 shall be met, regardless of where the examination was performed.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.6 - Use of HCPCS codes for home visits and house calls

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "House call" means a physician visit limited to the provision of medical care to an individual who is too ill to go to a physician's office and/or is "home bound" due to his or her physical condition.
(b) The house call codes do not distinguish between specialist and non-specialist reimbursement. House call codes apply when a detailed history, detailed examination and medical decision making of high complexity is provided.
(c) The home visit codes shall apply when the provider visits in the home setting and the visit does not meet the criteria specified in (a) and (b) above.
(d) When billing for a second or subsequent patient treated during the same visit, the visit shall be billed as a home visit, no matter what the complexity of care.
(e) House call and home visit codes shall not apply to visits to a residential health care facility or a nursing facility setting.
(f) In order to receive reimbursement for a house call or home visit, the documentation requirements set forth in 10:54-2.8 and 2.9 shall be met.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.7 - Use of HCPCS codes for emergency department services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When a physician sees his or her patient in the emergency room instead of his or her office, the physician shall use the same codes for the visit that would be used if the patient were seen in the physician's office (HCPCS 99211-99215 only). Records of the emergency room visit shall become part of the notes in the office chart.
(b) When a patient is seen by a hospital-based emergency room physician who is a Medicaid provider, then only the following "Visit" codes shall be used:
1. HCPCS 99281-99285.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.8 - Use of HCPCS codes for critical care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For critical care services to be covered by the Program, the HCPCS codes 99291 and 99292 shall be used and the service shall be consistent with the following requirement in order to be reimbursed:
1. The patient's situation requires constant physician attendance which is given by the physician to the exclusion of his or her other patients and duties and, therefore, for him or her, represents what is beyond usual service. This shall be verified by the applicable records, as defined by the setting. The records shall show, in the physician's handwriting, the time of onset and time of completion of the service.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.9 - Use of HCPCS codes for neonatal intensive care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For neonatal intensive care services to be covered by the Program, the codes HCPCS 99295-99297 shall be used and the service shall be consistent with the narrative in the CPT and with the following, in order to be reimbursed:
1. The patient's situation requires constant physician attendance which shall be given by the physician to the exclusion of his or her other patients and duties and, therefore, for him or her, represents what is beyond usual service. This must be verified by the applicable records, as defined by the setting. The records shall show in the physician's handwriting the time of onset and time of completion of the service.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.10 - Use of HCPCS codes for neonatal care; well baby

Current through Register Vol. 56, No. 14, July 15, 2024
For routine hospital newborn care for a well baby, the HCPCS code 99431 requires documentation, for reimbursement purposes, of minimum routine newborn care by a physician/practitioner other than the physician(s)/practitioner(s) rendering maternity service, complete initial and discharge physical examination, conference(s) with the patient(s).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.11 - Use of HCPCS codes for neonatal care; sick newborn

Current through Register Vol. 56, No. 14, July 15, 2024
For sick newborns in a hospital inpatient setting, HCPCS code 99221 shall be used for initial hospital care. HCPCS codes 99231, 99232, and 99233 shall be used for all other hospital care. If a prolonged period of hospital inpatient care is applicable, HCPCS codes 99356 and 99357 shall be used.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.12 - Physician reimbursement in special situations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A hospital-based physician who is salaried and whose services are reimbursed as part of the hospital's cost shall not bill fee-for-service to the New Jersey Medicaid/NJ FamilyCare program.
(b) A physician practicing in a hospital outpatient department whose reimbursement is not part of the hospital's cost may bill fee-for-service to the New Jersey Medicaid/NJ FamilyCare program, independent of the hospital charges for professional services, if the physician's arrangement with the hospital permits it.
(c) If a patient receives care from more than one member of a partnership or corporation in the same discipline, the maximum fee allowance shall be the same as that for a single attending physician.
(d) Reimbursement shall not be made for, and beneficiaries shall not be asked to pay for, broken appointments.
(e) Reimbursement shall be made for injections (intradermal, subcutaneous, intramuscular, intravenous) which are administered by the physician according to 10:54-9.4 and 10:54-9.8.
1. Reimbursement for immunization services will be based on the formula of Average Wholesale Price (AWP) of the drug plus 15 percent, plus $ 2.00 for physician's cost of dispensing the immunization. For specific qualifiers for immunizations, see 10:54-9.8(a) and (i) and 10:54-9.10(f).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.13 - HCPCS codes for surgical procedures; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare program shall reimburse for surgical services based on a surgical package concept, which includes the following components:
1. Pre-operative care, which shall include any consultations and/or evaluations performed within 48 hours prior to surgery by the surgeon performing the surgery and routine visits (office or hospital) on the day of surgery, except that:
i. Initial hospital visits may be reimbursed on the day of surgery, unless the surgery involves certain obstetrical delivery codes (see 10:54-9.10 for a listing of these delivery codes); and
ii. When the patient is undergoing same day surgery (hospital outpatient) or surgery in an ambulatory surgical center (independent clinic), the pre-surgical history, physical examination, and risk evaluation provided on the same day may be billed by the physician. (See also 10:54-9.4.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.14 - Pre-surgery consultation and evaluation

Current through Register Vol. 56, No. 14, July 15, 2024
Consultation and evaluation services provided prior to surgery by specialists other than the surgeon performing the procedure may be separately reimbursed from the payment for surgical procedures when provided within 48 hours prior to surgery.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.15 - Simultaneous visit and other procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If the physician bills for an office/outpatient visit at the time of the surgical procedure, reimbursement may be made for either the surgical procedure, at 100 percent of the Medicaid/NJ FamilyCare maximum fee allowance, or for the office/hospital outpatient visit.
(b) The following situations are exceptions to (a) above:
1. Venipuncture (HCPCS 36415) may be billed once per patient visit in addition to an office/hospital outpatient visit when the visit fulfills requirements of a visit and the sample is sent to an outside laboratory for processing;
2. Aspiration or injection into joints (HCPCS 20600-20610) may be billed with an office/hospital outpatient visit;
3. Medication injected into tendon sheaths, ligament trigger points or ganglion cysts (HCPCS 20550) may be billed with an office/hospital outpatient visit; and
4. Procedure codes listed in 10:54-9.4.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.16 - Multiple surgical procedures; same session

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Multiple surgical procedures during the same operative session shall be reimbursed as follows:
1. The primary surgical procedure shall be reimbursed at 100 percent of the Maximum Fee Allowance;
2. The secondary surgical procedure(s) shall be reimbursed at 50 percent of the Maximum Fee Allowance; and
3. The maximum reimbursement threshold for any operative procedure is 200 percent of the amount of the Maximum Fee Allowance of the primary surgical procedure.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.17 - Repeat or revisitation of the surgical procedure

Current through Register Vol. 56, No. 14, July 15, 2024
If the beneficiary is returned to the operative suite for a repeat or revisitation of the operation, by the same surgeon on the same day, the billing for the operative procedure shall include the "WB" modifier for the reimbursement for the second operative session. The use of this "WB" modifier permits separate reimbursement for the second operative session.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.18 - Ligation or transection of fallopian tubes

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Ligation or transection of fallopian tube(s), when done at the operative session (time) of a Caesarean Section or intra-abdominal surgery, shall be reimbursed by the New Jersey Medicaid/NJ FamilyCare program for additional reimbursement from the primary surgical procedure (Caesarean Section) or intra-abdominal surgery. The physician shall use HCPCS 58611 when billing for the ligation/transection of fallopian tube(s) done at the same operative session as the Caesarean Section or intra-abdominal surgery. Multiple surgery pricing shall not apply.
(b) The physician shall use HCPCS codes 58600 or 58605, when the ligation or transection of the fallopian tube(s) are not done at the same time as the operative session for intra-abdominal surgery. Multiple surgery pricing shall apply.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.19 - Anesthesiology

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Anesthesiologists shall be reimbursed for anesthesia services provided to a Medicaid/NJ FamilyCare program beneficiary for the total of the anesthesia base units (ABUs) plus anesthesia time.
(b) The use of a HCPCS procedure code which has anesthesia base units (ABUs) assigned requires that the "AA" modifier be utilized to allow the claim to be processed to adjudication. The physician shall enter the HCPCS procedure code and the "AA" modifier in FIELD 24D on the claim form.
(c) An "AA" modifier shall be used for either:
1. Services performed by an anesthesiologist; or
2. Services performed by a Certified Nurse Anesthetist (CRNA) personally and directly supervised by an anesthesiologist.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.20 - Radiology; general

Current through Register Vol. 56, No. 14, July 15, 2024
Radiological services shall ordinarily be provided only by a physician who is a specialist in radiology, nuclear medicine, and/or radiation oncology. However, a physician, other than one of those listed above, who is a specialist may provide radiological services which are related and limited to his or her own specialty field. (See 10:54-9.6, HCPCS for specific procedure codes and qualifiers for radiological services and the CPT.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.21 - Radiology; diagnostic imaging and ultrasound

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursement for radiological services provided by a physician(s) other than those physicians listed in 10:54-4.19 shall be limited to diagnostic radiology of long bones and/or radiological chest examination, in emergency situations to the physician's own patients, in his or her own office.
(b) The fees for routine diagnostic radiology shall include usual contrast media, equipment, materials, consultation, and written reports to the referring physician.
1. For special high risk patients who require the use of low osmolar contrast material to prevent adverse reactions, reimbursement shall be based on the volume of contrast injected, as specified in 10:54-9.6, HCPCS.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.22 - Radiology; Computerized Tomography (CT), Magnetic Resonance Imaging (MRI) and Ultrasound

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For documented, necessary, combined abdominal and pelvic body scans (CT and/or MRI), reimbursement for the second or subsequent procedures shall be limited to an additional 50 percent of the payment for the first procedure.
(b) For computerized tomography scan (CT) guidance (monitoring) performed in conjunction with biopsy, aspiration, puncture, injection of contrast material, or placement of a tube, drain, or other medically necessary device, the HCPCS codes with modifier for Reduced Services "-52" shall be used for billing purposes.
(c) Magnetic resonance imaging (MRI) shall be considered a covered service when provided in an inpatient or outpatient hospital setting, in an MRI consortium or in a physician's office. Reimbursement shall be contingent upon the provider of service and place of service.
1. When a hospital submits a claim for charges for an MRI service provided to an inpatient or outpatient, the technical component (TC) shall be separated from the professional component (PC).
i. The charge for the technical component (TC) provided to a hospital inpatient shall be billed by the hospital where the patient is registered as an inpatient, irrespective of where the MRI service is performed. When a hospital is providing an MRI service to an inpatient of another hospital, the hospital providing the service bills the charge to the referring hospital for reimbursement and the referring (inpatient) hospital bills the "rebundled charge" to the Medicaid/NJ FamilyCare program.
ii. The technical component (TC) provided to a hospital outpatient shall be billed by the hospital. The charge is subject to the Medicaid/NJ FamilyCare cost-to-charge ratio. (See N.J.A.C. 10:52.)
iii. For both hospital inpatients and outpatients, the professional component shall be billed on the CMS 1500 claim form, either by the physician or by the MRI-based hospital on behalf of the physician, and not on any other form.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.23 - Nuclear medicine; diagnostic and therapeutic radiopharmaceuticals

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Nuclear medicine, diagnostic and therapeutic radiopharmaceuticals shall be reimbursed separately when provided by a physician in an office setting, as applicable. (See HCPCS 78990 and 79900.)
1. Lung ventilation and perfusion study combined codes shall be used when both these studies are done on the same day, instead of the individual code for each study.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.24 - Radiation oncology; treatment planning and therapy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The treatment planning process shall include interpretation of special testing, tumor localization, treatment volume determination, treatment time/dosage determination, choice of treatment ports, selection of appropriate treatment devices and other procedures. Consultation services in conjunction with treatment planning shall not be separately reimbursed.
(b) Tele-radiotherapy treatment shall include the use of X-ray and other high energy modalities (such as betatron, or linear accelerator) radium, cobalt, and other radioactive substances, unless otherwise specified.
1. Reimbursement for treatment of malignancies and non-malignancies shall include 90 days follow-up care, unless otherwise specified.
2. Reimbursement for tele-radiotherapy shall include concomitant office visits, but shall not include concomitant surgical, diagnostic, radiological, or laboratory procedures.
3. Reimbursement of radium and radioisotopes shall include dosage calculation, preparation and planning of the treatment.
4. Reimbursement for radioactive drugs for treatment shall not be included in the therapeutic radiology reimbursement. Preliminary and follow-up diagnostic tests shall not be included in the reimbursement, and may be billed separately. (See the designation of particular HCPCS codes in 10:54-9.6.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.25 - Radiology; portable and mobile diagnostic

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Portable and mobile diagnostic radiological services shall be provided only by a physician who is a specialist in radiology.
(b) Portable and mobile diagnostic radiological services may be provided to Medicaid patients in long term care settings, in an emergency situation, or in a situation in which it is not medically practical to provide such services other than by bringing equipment and personnel to the patient for whom these services are indicated. No portable or mobile diagnostic radiological services provided in a boarding home or independent clinical laboratory shall be reimbursed by Medicaid.
(c) Portable and mobile diagnostic radiological services shall conform with Federal, State and local laws and regulations.
(d) Portable radiological services shall be rendered only on the written order of a licensed health professional within the limits of his or her licensure. The physician/practitioner ordering the service shall:
1. Define the body area to be radiologically examined;
2. Provide the diagnosis(es) indicating the reason for the order;
3. Indicate the current clinical status of the patient; and
4. Indicate dates and types of previous radiological examinations within past year.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.26 - Consultation services; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A consultation shall include a personal examination of the patient with a written report of the history, physical findings, diagnosis, and recommendations of the consultant for future management.
(b) When a consultation is requested from an approved State agency, a letter of agreement between the appropriate State agency and the New Jersey Medicaid/NJ FamilyCare program shall be made and the request shall be consistent with good medical practice. If there is a referral by a State agency with an appropriate contract with the New Jersey Medicaid/NJ FamilyCare program, the report shall be sent to the appropriate State agency and payment for a consultation may be reimbursed.
(c) If the consultation is performed in an emergency room setting and the patient is admitted within 24 hours to the consultant's service as an inpatient, either a consultation or initial visit may be billed. The Medicaid/NJ FamilyCare program will reimburse for only one, as appropriate. Continuing visits by the physician who has assumed the care of the patient shall be billed as subsequent hospital visits.
(d) If the patient is seen by another physician and admitted/transferred to that other physician's service, then the initial physician may continue to follow the patient and shall be reimbursed by the Medicaid/NJ FamilyCare program for concurrent care, if concurrent care can be justified as medically necessary. When a consultant assumes the continuing care of the patient, any subsequent services provided by him or her shall no longer be considered consultation, and these visits shall be billed as routine or follow-up visits. (See 10:54-4.7 for regulations on concurrent care.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.27 - Consultation; limited

Current through Register Vol. 56, No. 14, July 15, 2024
"Consultation (Limited)" refers, generally, to a single body system review and physical examination. While a limited consultation is not necessarily limited to a single body system, it does not include a complete, total, all inclusive history and complete, total, all inclusive physical examination. A written report which includes diagnosis and recommendations of future management shall be provided to the referring physician.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.28 - Consultation; comprehensive

Current through Register Vol. 56, No. 14, July 15, 2024
"Consultation (Comprehensive)" means a total body system evaluation by history and physical examination, including a total body systems review and total body system physical examination. If the total body system evaluation is not performed, reimbursement for comprehensive consultation may be made, provided evidence is documented on the medical record and accompanied by a statement that the consultation utilized one or more hours of the consulting physician's personal time in performance of the consultation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.29 - Consultation; follow-up

Current through Register Vol. 56, No. 14, July 15, 2024
"Consultation (Follow-up)" means the monitoring of progress, recommending management modifications or advising on a new plan of care in response to changes in the patient's status. If the physician consultant has initiated treatment at the initial consultation and participates thereafter in the patient's management, the codes for subsequent hospital care shall be used (99231-99233). Consultation (Follow-up) codes (99261-99263) shall be used for follow-up consultations provided to hospital inpatients and nursing facility residents only. For consultative services provided in other settings, the codes for office or other outpatient consultations shall be used (99241-99245).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.30 - Consultation; use of all consultation codes

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except where medical necessity dictates or where a hospital policy, state law or regulation dictates otherwise, multiple and simultaneous consultations in the same specialty for the same disease, illness or condition, whether in or out of a hospital, shall not be reimbursed.
(b) If there is no referring physician (such as, when the patient either makes an appointment on his own or when care is recommended by another physician who does not request a report of the specialist findings) or there is not an appropriate state agency referral, the appropriate initial office visit procedure code should be utilized rather than the code for consultation.
(c) If a consultation is performed in a nursing facility and the patient is then transferred to the service of the consultant, then the consultant shall bill for one of the consultation procedure codes or a COMPREHENSIVE NURSING FACILITY ASSESSMENTS (NEW or ESTABLISHED) for that visit and reimbursement will be for one, not both of these codes.
(d) If proper documentation is not forthcoming on the medical record, the consultation visit may be denied. One of the following statements shall be included on the medical record to indicate that a comprehensive consultation was performed by the physician.
1. "I personally performed a total (all) systems evaluation by history and physical examination"; or
2. "This consultation utilized one hour or more of my personal time."
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.31 - Concurrent care; physicians

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Concurrent care shall be reimbursed where medical necessity requires the services of more than one physician of the same or differing discipline or specialty, in addition to the primary or attending physician, for example:
1. A critically ill patient with diverse medical condition requiring the services of two or more internists, that is, diabetic specialist and cardiologist; or
2. A patient requires an orthopedist for a fractured leg, a neurosurgeon for a head injury, and a general surgeon for a ruptured abdominal viscus, plus an internist for the stabilization of uncontrolled diabetes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.32 - Concurrent care/collaboration with an APN

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This rule applies when a physician is providing concurrent care with an advanced practice nurse whether employed as part of a group, or if the physician provides collaboration to the APN.
(b) When an APN is employed by a physician/practitioner group, the Medicaid/NJ FamilyCare program shall not reimburse both an APN visit and, on the same day, a visit to an MD or DO within the same billing entity, except when specific circumstances require two same-day visits. In such case, the provider entity shall document the medical necessity for the second visit (see concurrent care below).
(c) If a patient receives care from more than one member of a group practice, a partnership or corporation in the same specialty, the maximum fee allowance (total) would be the same as that for a single practitioner.
(d) APN and physician concurrent care will be reimbursed under the following circumstances:
1. If concurrent care is provided, it shall be clearly documented that significant medical necessity exists for more than one clinician's services, as defined at 10:54-1.2, and
2. At such time as the patient's condition permits, the primary practitioner/physician shall either resume sole responsibility or transfer the patient to the practitioner/physician supplying additional (concurrent) care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 4 - BASIS OF PAYMENT › Section 10:54-4.33 - Services provided in a birthing center

Current through Register Vol. 56, No. 14, July 15, 2024
A physician may bill the Medicaid/NJ FamilyCare program directly for medical care provided in a birth center. These services may include assistance or consultation related to the delivery or pediatric medical care or a pediatric consultation to the infant. All services provided must meet all applicable requirements for the procedure billed as otherwise required in this subchapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 5 - POLICIES AND PROCEDURES FOR PROVISION OF SERVICES PRESCRIBED OR RENDERED BY A PHYSICIAN › Section 10:54-5.1 - Apnea monitors; home

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare program shall reimburse durable medical service providers for the use of home apnea monitors under the provisions of N.J.A.C. 10:59 and 10:54-5.2 and 5.3.
(b) When an order or prescription for a home apnea monitor is received by the durable medical equipment (DME) provider, the DME provider shall complete and the prescribing physician shall sign a "Home Apnea Monitor Certification" form (FD-287) and the DME provider shall forward it along with the CMS 1500 claim form to the appropriate Medical Assistance Customer Center (MACC) for the initial prior authorization.
1. Each request by a physician shall include written medical data for the medical necessity of the monitor based on the recent evaluation by the physician.
2. Durable medical equipment (DME) providers may use their own Medical Necessity forms in place of, or in conjunction with, the FD-287 as long as all information required on the FD-287 form appears on the Medical Necessity forms.
3. In an urgent situation requiring immediate action, the DME provider may supply the home apnea monitor. However, this action shall be documented in the written request for authorization, which shall be submitted to the MACC no later than 10 working days following the receipt of the physician's order or prescription.
4. Prior authorization shall be issued for up to three months. Failure to obtain prior authorization will result in administrative denial.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 5 - POLICIES AND PROCEDURES FOR PROVISION OF SERVICES PRESCRIBED OR RENDERED BY A PHYSICIAN › Section 10:54-5.2 - Clinical laboratory services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Clinical laboratory services" means professional and technical laboratory services performed by a clinical laboratory certified by CMS in accordance with the Clinical Laboratory Improvement Act (CLIA) and ordered by a physician or other licensed practitioner (including the certified nurse midwife and advanced practice nurse), within the scope of his or her practice as defined by the laws of the State of New Jersey or of the state in which the physician or practitioner practices.
(b) Clinical laboratory services are furnished by clinical laboratories and by physician office laboratories (POLs) that meet the Centers for Medicare and Medicaid Services 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. §
										1396(a)(9), and as indicated at 10:61-1.2, the Medicaid/NJ FamilyCare program's Independent Clinical Laboratory Services chapter, and N.J.A.C. 8:44 and 8:45.
(c) All independent clinical laboratories and other entities performing clinical laboratory testing shall possess one of the following certificates:
1. Certificate of Registration or Registration Certificate;
2. Certificate of Waiver;
3. Certificate for Provider-Performed Microscopy (PPM) Procedures;
4. Certificate of Compliance; or
5. Certificate of Accreditation.
(For certification information, contact the Centers for Medicare and Medicaid Services, CLIA Program, P.O. Box 26689, Baltimore, MD 21207-0489.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 5 - POLICIES AND PROCEDURES FOR PROVISION OF SERVICES PRESCRIBED OR RENDERED BY A PHYSICIAN › Section 10:54-5.3 - Cosmetic surgery

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Cosmetic surgery means that surgery, which is performed solely for the purpose of beautifying an individual and which has no significant redeeming medical necessity. For purposes of the New Jersey Medicaid/NJ FamilyCare program, cosmetic surgery is not a covered or reimbursable service, except as specified in (b) below.
(b) If significant redeeming medical necessity can be demonstrated, the medical consultant in the Medical Assistance Customer Center (MACC) will consider a request from a physician for prior authorization to perform such surgery. Such requests shall be submitted in writing and shall include photographs, when indicated, to support the request. The physician shall obtain prior authorization from the Medical Assistance Customer Center before this service is rendered. (See directory of Medical Assistance Customer Centers at N.J.A.C. 10:49, Appendix.)
(c) Repair or reconstruction of changes due to trauma, infection or surgery whose need for correction demonstrates a significant medical necessity is not considered cosmetic surgery within the intent of the New Jersey Medicaid/NJ FamilyCare program and therefore would not require prior authorization.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 5 - POLICIES AND PROCEDURES FOR PROVISION OF SERVICES PRESCRIBED OR RENDERED BY A PHYSICIAN › Section 10:54-5.4 - Diagnostic endoscopic procedures; general

Current through Register Vol. 56, No. 14, July 15, 2024
Payment for endoscopic procedures shall be made in accordance with 10:54-5.5, 5.6, and 5.9.