reglab/statecodes huggingface dataset:
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 10:54-5.5 - Diagnostic endoscopic procedure; without biopsies

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For diagnostic endoscopic procedures which do not involve biopsy(ies), if an endoscopic procedure is performed as a single procedure, the maximum reimbursement shall be 100 percent of the HCPCS code.
(b) Reimbursement shall be made for either the endoscopic procedure or the office or outpatient visit, but not for both.
(c) Nasal endoscopy (HCPCS 31231-31235) without the 22 modifier (without biopsy) shall not be reimbursed in combination with other diagnostic endoscopies involving the respiratory system performed by the same physician at the same session.
(d) If two or more diagnostic endoscopic procedures are performed by the same physician during a single session and each procedure involves a different body system (as outlined in the CPT-4 classification system) each endoscopic procedure may be billed and may be reimbursed at 100 percent of the Medicaid/NJ FamilyCare Maximum Fee Allowance.
(e) Except as specified in (f) below, if two or more diagnostic endoscopic procedures involving the same body system (as outlined in the CPT classification system) are performed by the same physician during a single session, the physician shall claim and may be reimbursed for the endoscopic procedure involving only the "deepest penetration." (Often, but not always, the higher HCPCS code number in the CPT corresponds to the endoscopic procedure that has the "deeper penetration.") In this situation, only this one endoscopic procedure shall be reimbursed.
(f) When certain multiple (two or more) endoscopic procedures are defined as complex and/or involve another, different anatomical site necessitating the use of a different scope and the initiation of an independent procedure, the physician shall request reimbursement for each procedure separately at 100 percent of the Medicaid/NJ FamilyCare Maximum Fee Allowance. (See 10:54-9.4 on HCPCS for a list of these procedures.)
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 10:54-5.6 - Diagnostic endoscopic procedures; with biopsy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For diagnostic endoscopic procedures with biopsies, the pricing logic for multiple surgical procedures applies (see 10:54-4.15 ). In some instances, there is a specific CPT (HCPCS) code associated with that procedure which includes the biopsy and that HCPCS code must be used when requesting reimbursement.
(b) The modifier 22 shall be used with the HCPCS which designates the diagnostic endoscopic procedures with a biopsy when the code does not specifically designate a biopsy. The multiple procedure surgical pricing logic does apply to the reimbursement of these codes. (See also 10:54-9.5 under each specific code.)
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 10:54-5.7 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT); general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is a comprehensive health program for Medicaid/NJ FamilyCare program beneficiaries under 21 years of age. The goal of the program is to assess the beneficiaries health needs through initial and periodic examinations (screenings); to provide health education and guidance; and to assure that health problems are prevented; or diagnosed and treated at the earliest possible time.
(b) For the certification criteria that a physician must meet in providing services to children under 21 years of age, see N.J.A.C. 10:54-1.
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 10:54-5.8 - EPSDT; conditions of participation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) As a condition of participation in Medicaid/NJ FamilyCare, all ambulatory care facilities (including hospital outpatient departments) providing primary care to children and adolescents from birth through 20 years of age, shall participate in the EPSDT program and shall provide, at a minimum, the required EPSDT screening services.
(b) EPSDT screening services, vision services, dental services, and hearing services shall be provided at defined intervals as recommended by the appropriate professional organizations.
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 10:54-5.9 - EPSDT; services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The required EPSDT services include the following:
1. Screening services (see (f) below for components of screening services);
2. Vision services;
3. Dental services;
4. Hearing services; and,
5. Other medically necessary health care, diagnostic services and treatment and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services.
i. For requirements for prior authorization for organ procurement and transplant services in general, see 10:54-5.32(a) and (d). For requirements for prior authorization for organ procurement and transplantation services for Medicaid/NJ FamilyCare program beneficiaries of EPSDT services, see 10:54-5.32(d).
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 10:54-5.10 - EPSDT screening periodicity schedule

Current through Register Vol. 56, No. 14, July 15, 2024
(a) EPSDT screening services shall be provided periodically according to the following schedule which reflects the age of the child:
1. Under six weeks; two months; four months; six months; nine months; 12 months; 15 months; 18 months; 24 months; and annually through age 20 years.
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 10:54-5.11 - EPSDT vision screening

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Vision screening shall include the following:
1. A newborn examination including general inspection of the eyes, visualization of the red reflex and evaluation of ocular motility;
2. An appropriate medical and family history;
3. An evaluation, by age six months, of eye fixation preference, muscle imbalance, and pupillary light reflex; and
4. A third examination with visual acuity testing by age three or four years.
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 10:54-5.12 - EPSDT dental screening

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Dental screening shall include the following:
1. An intraoral examination which is an integral part of a general physical examination meaning observation of tooth eruption, occlusion pattern, and presence of caries or oral infection;
2. A formal referral to a dentist is recommended at one year of age; it is mandatory for children three years of age and older; and
3. Dental inspection and prophylaxis that should be carried out every six months until 17 years of age, then annually.
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 10:54-5.13 - EPSDT hearing screening

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An individual hearing screening should be administered annually to all children through age eight and to all childen at risk of hearing impairment; and
(b) In addition to what is required in (a) above, after eight years of age, children shall be screened every other year.
(c) A hearing screening shall include, at a minimum, an observation of an infant's response to auditory stimuli. Speech and hearing assessment shall be part of each preventive visit for an older child. An objective audiometric test, such as a pure tone screening test, if performed as part of an EPSDT screening examination, is eligible for separate reimbursement.
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 10:54-5.14 - EPSDT and pediatric HealthStart

Current through Register Vol. 56, No. 14, July 15, 2024
(a) EPSDT providers may apply to the New Jersey Department of Health and Senior Services for certification as Pediatric HealthStart providers.
(b) HealthStart is a program of enhanced maternity care and preventive health care for children under 2 years of age. Certified Pediatric HealthStart providers agree to assure continuity of care by following up on referrals and missed appointments, making available 24 hour telephone access and sick care, either directly or by formal arrangement with another pediatric provider.
(c) Pediatric HealthStart providers are approved for a higher reimbursement for preventive child health examinations (screening) than other EPSDT providers, in accordance with the requirements of N.J.A.C. 10:54-6.
(d) EPSDT/HealthStart screening services are billed on the Report and Claim for EPSDT/HealthStart Screening and Related Procedure Form using HealthStart specific procedure codes as listed in 10:54-9.4, 10:54-9.10(l), and 10:54-9.10(k).
(e) EPSDT/HealthStart claims shall be submitted within 30 days of the date of service.
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 10:54-5.15 - Family planning services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Payment shall be made for medically necessary family planning services, including medical history and physical examination (including pelvis and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling.
(b) Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals and related office visit, drugs, laboratory services, radiological and diagnostic services and surgical procedures are not covered by the New Jersey Medicaid/NJ FamilyCare program, except:
1. When a service is provided that is ordinarily considered an infertility service, but is provided for another purpose. In such case, the physician shall submit the claim with supporting documentation for medical review and approval of payment to the Division of Medical Assistance and Health Services, Office of Utilization Management, PO Box 712, Mail Code #14, Trenton, New Jersey 08625-0712.
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 10:54-5.16 - Home Care Services; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following groups or programs of services or programs are included under Home Care Services:
1. Home Health Services (HH);
2. Personal Care Assistant Services (PCA); and
3. Home and Community-Based Services Waiver programs, including:
i. Global Options for Long-Term Care (GO), operated by the Department of Health and Senior Services (DHSS);
ii. AIDS Community Care Alternatives program (ACCAP), operated by the Division of Disability Services (DDS);
iii. Community Resources for People with Disabilities (CRPD), operated by DDS;
iv. Home and Community-Based Services Waiver for Persons with Traumatic Brain Injury Program (TBI), operated by DDS; and
v. Home and Community-Based Services Waiver for Mentally Retarded/Developmentally Disabled (CCW) operated by the Division of Developmental Disabilities (DDD).
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 10:54-5.17 - Home Care Services; Home Health Services (HH)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medicaid reimbursement shall be limited to home health services provided by Medicare-certified, New Jersey State Department of Health and Senior Services-licensed home health agency that is a participating provider in the New Jersey Medicaid/NJ FamilyCare program. (See N.J.A.C. 8:42 and 10:60-1.2.)
(b) Home Health services shall be prescribed by a physician and shall be directed toward rehabilitation and/or restoration of the beneficiary to the optimal level of physical and/or mental functioning, self-care and independence; or directed toward maintaining the present level of functioning.
(c) Home Health services include the following: professional nursing visits; home health aide services; physical therapy; occupational therapy; speech-language pathology and audiological services; medical social work services; nutritional services; certain medical supplies and equipment; and personal care assistant services.
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 10:54-5.18 - Home Care Services; Personal Care Assistant Services (PCA)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Personal care assistant services may be provided by a Medicare-certified, licensed home health agency or by an accredited proprietary or voluntary non-profit homemaker agency approved to participate as a provider of services in the New Jersey Medicaid/NJ FamilyCare program, in accordance with 10:60-1.2.
(b) Personal care assistant services are health related tasks performed in a beneficiary's home, prescribed by a physician in accordance with the patient's written plan of care, and provided by an individual who is:
1. Certified as a homemaker/home health aide by the New Jersey State Board of Nursing; and
2. Supervised by a registered professional nurse; and
3. Not a member of the patient's family.
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 10:54-5.19 - Home Care Services; Home and Community-Based Services Waiver programs eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Financial eligibility for Medicaid for Home and Community-Based Services Waiver programs will be determined by either the county welfare agency (CWA) or by the Social Security Administration.
(b) Clinical eligibility for Medicaid for Home and Community-Based Services Waiver programs will be determined by the professional staff designated by the Department of Health and Senior Services (DHSS), based on a comprehensive needs assessment that demonstrates that the beneficiary requires, at a minimum, basic nursing facility services as described in N.J.A.C. 8:85, Long-Term Care Services.
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 10:54-5.20 - Home Care Services; Home and Community-Based Services Waiver programs; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Individuals served in the Home and Community-Based Services Waiver program shall be medically in need of nursing facility care, as determined by the professional staff designated by the Department of Health and Senior Services but elect to remain at home with community-based services.
(b) The cost of providing home care services for a beneficiary enrolled in a Home and Community-Based Waiver shall not exceed the cost of institutional care.
(c) Home and Community-Based Waiver services are provided within a case managed delivery system, as follows:
1. "Case/Care Management" means a system in which a social worker or professional nurse is responsible for the planning, locating, coordinating and monitoring of a group of services designed to meet the health needs of the Medicaid beneficiaries being served. The case manager is responsible for the initial and ongoing assessment of the need for home care services and is the pivotal person in establishing a service plan to meet those needs.
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 10:54-5.21 - Home Care Services; Community Resources for People with Disabilities (CRPD) Waiver Services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Community Resources for People with Disabilities (CRPD) Waiver Services offer all New Jersey (Title XIX) Medicaid services except nursing facility services. In addition to all regular Medicaid services, the following services may be offered as part of CRPD services:
1. Case/care management;
2. Private duty nursing;
3. Environmental/vehicular modifications;
4. Personal emergency response system (PERS); and
5. Community transitional services (CTS).
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 10:54-5.22 - Home Care Services; AIDS Community Care Alternatives Program (ACCAP)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The AIDS Community Care Alternatives Program (ACCAP) offers all New Jersey (Title XIX) Medicaid services, except nursing facility services to children and adults with the AIDS diagnosis and to children up to the age of five who are HIV positive. In addition to all regular Medicaid services, the following services are offered as part of ACCAP:
1. Case management;
2. Private duty nursing;
3. Specialized group foster home care for children;
4. Specialized medical day care;
5. Expanded hours of personal care assistant services;
6. Certain narcotic and drug abuse treatment at home;
7. Hospice care; and
8. Intensive supervision to children who reside in Division of Youth and Family Service (DYFS) supervised foster care homes.
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 10:54-5.23 - Home Care Services; Global Options for Long-Term Care (GO)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Global Options (GO) waiver program offers all New Jersey (Title XIX) Medicaid services, to eligible adults age 65 years of age and older and to adults between the ages of 21-64, who are permanently physically disabled. In addition to all regular Medicaid services, a GO participant will receive care/case management services and a minimum of one of the additional waiver services listed below:
1. Assisted living;
2. Adult family care;
3. Attendant care;
4. Caregiver/participant training;
5. Chore service;
6. Community transition services;
7. Environmental Accessibility Adaptations (EAA);
8. Home-Based Supportive Care (HBSC);
9. Home-delivered meals;
10. Personal Emergency Response System (PERS);
11. Respite care;
12. Specialized medical equipment and supplies;
13. Social adult day care;
14. Transitional care management; and
15. Transportation.
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 10:54-5.24 - Home Care Services; Home and Community-Based Services Waiver Program for persons with traumatic brain injuries (TBI)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Home and Community-Based Services Waiver for Persons with Traumatic Brain Injuries (TBI) offers home and community-based services to a beneficiary with an acquired traumatic brain injury to help him or her remain in the community, or return to the community rather than be cared for in a nursing facility. All regular Medicaid services, except nursing facility services, are offered as part of TBI program. In addition, the following services are offered:
1. Case management;
2. Personal care assistant;
3. Respite care;
4. Environmental modification;
5. Transportation;
6. Chore services;
7. Companion services;
8. Therapy services (including physical and occupational therapy, speech-language pathology and cognitive therapy services);
9. Community residential services;
10. Night supervision services;
11. Structured and supported day program services;
12. Counseling; and
13. Behavioral program services.
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 10:54-5.26 - Home Care Services; Home and Community-Based Waiver for Mentally Retarded/Developmentally Disabled (CCW)

Current through Register Vol. 56, No. 14, July 15, 2024
The Home and Community-Based Care Waiver for Mentally Retarded/Developmentally Disabled (CCW) offers all New Jersey (Title XIX) Medicaid services, except nursing facility services, to eligible mentally retarded individuals receiving services from the Division of Developmental Disabilities (DDD). Additionally, DDD-CCW offers case management, personal care, habilitation and respite care. DDD has the responsibility for the overall administration of the program.
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 10:54-5.28 - Home Care Services; private duty nursing for EPSDT

Current through Register Vol. 56, No. 14, July 15, 2024
For the policy related to private duty nursing services in a home setting for Medicaid/NJ FamilyCare program beneficiaries of EPSDT services, see Home Care Services, 10:60-1.3(b)  and 1.12(b) and (c).
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 10:54-5.29 - Hospice services; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare program provides hospice services under N.J.A.C. 10:60-2.15(a)7  and 3.16(a)7, the AIDS Community Care Alternatives Program (ACCAP) and 10:53A-3.4, hospice services to other Medicaid beneficiaries.
(b) Hospice care under the ACCAP program shall be approved by the attending physician and available to ACCAP beneficiaries on a 24-hour a day basis, as needed, in accordance with the beneficiary's plan of care, by a Medicaid/NJ FamilyCare approved, Medicare certified hospice agency. Reimbursement shall be at an established fee paid on a per diem basis to the hospice. Hospice services under ACCAP include only:
1. Services within the home;
2. Skilled nursing visits;
3. Hospice agency medical director services;
4. Medical social service visits;
5. Occupational therapy, physical therapy and speech-language pathology services;
6. Intravenous therapy;
7. Durable medical equipment;
8. Medication related to symptom control of the terminal illness; and
9. Case management as part of the hospice service.
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 10:54-5.30 - Medical supplies and durable medical equipment (DME) services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Medical supplies" means item(s), which are:
1. Consumable, expendable, disposable or non-durable;
2. Prescribed by the physician or practitioner (See 10:59-1.2 for further description); and
3. Medically necessary for use by a Medicaid/NJ FamilyCare program beneficiary (for example, suction catheters).
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 10:54-5.31 - Nursing facility services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An attending physician shall prescribe, and certify in the medical record, the medical necessity for nursing facility services for a Medicaid/NJ FamilyCare program patient.
(b) When physician services are provided to a patient in a nursing facility (formerly known as a skilled nursing facility or an intermediate care facility), reimbursement will not be made to any physician or practitioner, or for therapy or services rendered by an owner, partner, administrator, officer, or stockholder of the company or corporation or anyone who otherwise has a direct or indirect financial interest in the institution; except that:
1. A medical director who is neither an owner, partner, official, stockholder of the company or corporation, but who is reimbursed a salary by the facility for administrative purposes, may bill on a fee-for-service basis for medical services rendered by him to patients in that facility.
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 10:54-5.32 - Organ procurement and transplantation services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division covers services rendered and items dispensed or furnished in connection with organ procurement and transplantation services of kidney, heart, heart-lung, liver, bone marrow, cornea and other selected medically necessary organ transplants except those transplants categorized as experimental. (See (d) below for further information on organ procurement and transplantation.)
1. Payment for organ procurement and transplant services rendered to or items dispensed or furnished a donor will be considered a charge on behalf of the Medicaid beneficiary who is the transplant beneficiary.
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 10:54-5.33 - Orthopedic footwear services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For purposes of the New Jersey Medicaid/NJ FamilyCare program, "an orthopedic shoe" means footwear, with or without accompanying appliances, used to prevent or correct gross deformities of the feet, which is properly fitted as to length and width, and consists of the following basic parts:
1. Correct straight last line;
2. Heels with sufficient bearing surface;
3. Toe with ample room for function;
4. Sole of sufficient weight for foot protection;
5. Rigid shank;
6. Properly fitting upper;
7. Smooth and protective lining; and
8. Snug fitting heel counter.
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 10:54-5.34 - Prosthetic and orthotic services (P & O)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Custom-made prosthetic and orthotic appliances (required to replace, support or strengthen parts of the body) are allowable when prescribed by a licensed physician. For purpose of the New Jersey Medicaid/NJ FamilyCare program, "custom-made" means a device or appliance fabricated (constructed and/or assembled) in an approved facility under the specific direction of a prescribing physician and designed to fit and perform a useful function solely for that specific individual for whom it was ordered.
1. Custom-made appliances must be fabricated by a person certified as a prosthetist and/or orthotist by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, incorporated and fabricated in a facility accredited by the same certification board. The facility must be approved by the New Jersey Medicaid/NJ FamilyCare program to provide either prosthetic or orthotic (P & O) services or both to Medicaid/NJ FamilyCare program beneficiaries. The physician may contact the Medical Assistance Customer Center to determine which P & O dealers are eligible under the program. The P & O provider must obtain prior authorization from the Medical Assistance Customer Center to provide these services. For a listing of Medical Assistance Customer Centers, see the end of N.J.A.C. 10:49, Administration Manual, or the list can be downloaded free of charge from the Division of Medical Assistance and Health Services' website:
http://www.state.nj.us/humanservices/dmahs/home/index.html
.
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 10:54-5.35 - Rehabilitative services; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Rehabilitative services include physical therapy, occupational therapy, and speech-language pathology and audiology, including the use of such supplies and equipment as are necessary in the provision of such services. Rehabilitative services and other restorative services are provided for the purpose of attaining maximum reduction of physical or mental disability and restoration of a Medicaid/NJ FamilyCare beneficiary to his or her best functional level. Rehabilitative services shall be made available to Medicaid/NJ FamilyCare beneficiaries as an integral part of a comprehensive medical program.
(b) In a physician's office, rehabilitative services shall be provided by or under the direction of a physical therapist, occupational therapist, speech-language pathologist or audiologist employed by or under contract to the physician. Each of these therapy services are discussed at 10:54-5.36, 5.37 and 5.38, respectively.
1. Physical therapy, occupational therapy, speech-language pathology and audiology services shall be reimbursed directly to the physician only when provided in the physician's office.
2. Physical therapy and speech-language therapy treatments shall be individual and shall consist of a minimum of 30 minutes.
3. Audiology services shall be reimbursed only when services are provided in an office of an Ear, Nose and Throat Specialist.
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 10:54-5.36 - Rehabilitative services; physical therapy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Physical therapy is a service prescribed by a physician and provided to a Medicaid/NJ FamilyCare beneficiary by or under the direction of a qualified physical therapist. Physical therapy does not include therapy which is purely palliative, such as the application of heat in any form; massage, routine calisthenics; group exercises; assistance in any activity; use of a simple mechanical device; or other services not requiring the special skill of a licensed physical therapist.
1. A qualified physical therapist is an individual who is:
i. Licensed by the State of New Jersey as a physical therapist in accordance with N.J.A.C. 13:39A; and
ii. A graduate of a program of physical therapy approved by both the Committee on Allied Health Education and Accreditation of the American Medical Association and the American Physical Therapy Association or its equivalent.
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 10:54-5.37 - Rehabilitative services; occupational therapy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Occupational therapy is a service prescribed by a physician and provided to a Medicaid/NJ FamilyCare beneficiary by or under the direction of a qualified occupational therapist and includes the necessary supplies and equipment.
1. A qualified occupational therapist is an individual who is:
i. Registered by the American Occupational Therapy Certification Board (AOTCB); or
ii. A graduate of a program in occupational therapy approved by the Committee on Allied Health Education of the American Medical Association and engaged in the supplemental clinical experience required before registration by the American Occupational Therapy Association (AOTA).
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 10:54-5.38 - Rehabilitative services; speech-language pathology and audiology

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Speech-language pathology services and audiology services are diagnostic, screening, preventive, or corrective services prescribed by a physician and provided to a Medicaid/NJ FamilyCare beneficiary by or under the direction of a speech-language pathologist or audiologist. They include necessary supplies and equipment.
1. A speech-language pathologist or audiologist is an individual who is licensed by the State of New Jersey as a speech-language pathologist or audiologist, in accordance with N.J.A.C. 13:44C, and who meets all applicable Federal requirements including:
i. A certificate of clinical competence in Speech-Language Pathology or Audiology from the American Speech-Language-Hearing Association; or
ii. Completion of the equivalent educational requirements and work experience necessary for the certificate(s); or
iii. Completion of the academic program and is in the process of acquiring supervised work experience in order to qualify for the certificate(s).
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 10:54-5.39 - Rehabilitative services; separation of therapy and office visit reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No portion of the time spent on therapy treatments may be considered as part of the time parameters of an office visit. Office visits billed during the same day shall clearly and separately meet the time and other parameters described in the applicable HCPCS procedure codes, N.J.A.C. 10:54-9.
(b) When the same type of rehabilitative service is performed on a Medicaid/NJ FamilyCare beneficiary more than once on the same day, for example, two physical therapy services, reimbursement shall be made for one service only. Likewise, when the treatment performed on a Medicaid/NJ FamilyCare beneficiary is merely a different modality within the same type of rehabilitative service, reimbursement shall be made for only one service per beneficiary per day.
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 10:54-5.40 - Second opinion program for elective surgical procedures-hospital inpatient and ambulatory surgical centers (ASC) services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A second opinion shall be required for the elective surgical procedures listed under (b) below. The outcome of the second opinion will have no bearing on payment. Once the second opinion is rendered, the patient will retain the right to decide whether or not to proceed with the surgery; however, failure to obtain a second opinion for these procedures will result in a denial of the surgeon's claim. (See 10:54-9.11(c) and (d) for the list of HCPCS codes that require a second opinion.)
1. A second opinion shall be required for the surgery indicated below when the surgical procedure is elective. If the operating physician determines that the need for surgery is urgent or is an emergency, no opinion is required. Urgent or emergency (for second opinion purposes) includes any situation in which a delay in performing surgery in order to meet the second opinion requirement could result in a significant threat to the patient's health or life.
i. If the patient is hospitalized or admitted to an ASC, a second opinion is not required if the procedure becomes urgent or an emergency during the course of the hospitalization or admission, regardless of the patient's admitting diagnosis.
ii. Reimbursement for urgent or emergency surgery shall be made only if a specific statement is attached to the claim form by the operating physician certifying that the second opinion requirement was not met and substantiating the urgent or emergency nature of the surgery.
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 10:54-5.41 - Sterilization; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division covers sterilization procedures performed on Medicaid/NJ FamilyCare program beneficiaries based on Federal regulations ( 42 CFR 441.250 through 441.258 ) and related requirements outlined in this section and in the billing instructions. For sterilization policy and procedures, see (b) through (e) below. Billing instructions are outlined in the Fiscal Agent Billing Supplement.
(b) "Sterilization" means any surgical procedure, treatment, or operation, for the purpose of rendering an individual permanently incapable of reproducing. Surgical sterilization procedures are those whose primary purpose is to render an individual incapable of reproducing. Surgical sterilization procedures require the completion of the Federal "Consent Form" for sterilization.
(c) In accordance with 42 CFR 441.258 Appendix to Subpart F (Specific Requirements for Use), the following requirements shall be met and/or documented on the Consent Form prior to the sterilization of an individual:
1. The individual is at least 21 years of age at the time the consent is obtained;
2. The individual is not mentally incompetent. "Mentally incompetent individual" means an individual who has been declared mentally incompetent by a Federal, state, or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to sterilization;
3. The individual is not institutionalized. "Institutionalized individual" means an individual who is:
i. Involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental hospital or other facility for the care and treatment of mental illness; or
ii. Confined, under a voluntary commitment, in a mental hospital or other facility for the care and treatment of mental illness;
4. The individual has voluntarily given informed consent;
5. At least 30 days, but not more than 180 days, have passed between the date of informed consent and the date of sterilization, except in the case of emergency abdominal surgery or premature delivery;
i. In the case of emergency abdominal surgery at least 72 hours shall have passed between the date he or she gave informed consent and the date of sterilization;
ii. In the case of premature delivery, informed consent shall have been given at least 30 days before the expected date of delivery and at least 72 hours have passed between the date of informed consent and the date of premature delivery.
6. In the case where a patient desires to be sterilized at the time of delivery, the Consent Form shall be signed by the patient no earlier than the 5th month of pregnancy to minimize the possibility of exceeding the 180 day limit.
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 10:54-5.42 - Hysterectomy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division will cover hysterectomy procedures performed on Medicaid beneficiaries based on Federal regulation ( 42 CFR 441.250 through 42 CFR 441.258 ) and related requirements outlined in the billing instructions. For billing instructions, see Fiscal Agent Billing Supplement, Appendix B.
(b) "Hysterectomy" means an operation for the purpose of removing the uterus.
1. A hysterectomy shall not be performed solely for the purpose of rendering an individual permanently incapable of reproducing. A hysterectomy shall be covered as a surgical procedure if performed primarily for the purpose of removing a pathological organ.
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 10:54-5.43 - Termination of pregnancy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division shall reimburse for medically necessary termination of pregnancy procedures on Medicaid/NJ FamilyCare program beneficiaries when performed by a physician in accordance with 13:35-4.2, of the rules of the New Jersey State Department of Law and Safety, Division of Consumer Affairs, Board of Medical Examiners.
(b) A physician may take the following factors into consideration in determining whether a termination of pregnancy is medically necessary on a Medicaid/NJ FamilyCare program beneficiary:
1. To save the life of the mother;
2. That the pregnancy was the result of an act of rape;
3. That the pregnancy was the result of an act of incest; or
4. That in the physician's professional judgment, the termination was medically necessary and consistent with the Federal court ruling that a physician may take the following factors into consideration in determining whether a termination of pregnancy is medically necessary:
i. Physical, emotional and psychological factors;
ii. Family reasons; and
iii. Age.
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 10:54-5.44 - Transportation services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division recognizes transportation services as covered services when a beneficiary is transported for the purpose of obtaining a Medicaid/NJ FamilyCare covered service. The mode of transportation is based upon the beneficiary's medical condition, as follows:
1. An ambulatory patient who does not require assistance or supervision shall be eligible for "lower mode" transportation (that is, car, bus, train or taxi);
2. A wheelchair-bound patient who does not need emergency ambulance service and/or a patient who is physically unable to use public conveyances shall be eligible for invalid coach service;
3. When emergency service is needed or the beneficiary is stretcher-bound, the beneficiary may obtain ambulance service directly from a provider of ambulance service, including Mobile Intensive Care Unit (MICU) service or air ambulance service when these modes of transportation are medically justified;
4. Non-emergency medical ground transportation services shall be provided by an independent transportation broker or vendor under contract with the Division of Medical Assistance and Health Services. This includes, but is not limited to:
i. Ground ambulance service (non emergency);
ii. Mobility assistance vehicle service;
iii. Livery services, including modified livery services; and
iv. All lower-mode transportation services, including arranging for transportation by taxi, train, bus, plane or other public conveyance;
5. Emergency ground transportation services and all air ambulance services shall be provided by transportation providers enrolled in the Medicaid/NJ FamilyCare program in accordance with 10:49-3.2 and 10:50; and
6. In all cases, the least expensive mode of transportation appropriate to the beneficiary's medical needs shall be used.
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 10:54-5.45 - Vision care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division recognizes vision care services, and optical appliances and services provided only by the following eligible providers, within the restrictions of their respective licensure or requirements in the state in which they are located:
1. An ophthalmologist means a licensed physician who is a diplomate of the American Board of Ophthalmology or who has been recognized by the New Jersey Medicaid/NJ FamilyCare program as a specialist in ophthalmology;
2. An optometrist means a person who is licensed by the New Jersey State Board of Optometry to engage in the practice of optometry, or similarly licensed by a comparable agency of the state in which he or she performs such functions;
3. An optician means a person licensed by the New Jersey State Board of Examiners of Ophthalmic Dispensers and Ophthalmic Technicians, or similarly licensed by a comparable agency of the state in which he or she performs such functions;
4. A recognized ocularist who provides artificial eyes, upon the recommendation of a prescribing practitioner. (See the Vision Care Services Chapter at N.J.A.C. 10:62-3 );
5. An independent clinic approved by the Division to render eye care services;
6. Hospital meeting the definition of an approved general hospital, approved special hospital, or approved private or state and county governmental psychiatric hospital, as adhering the conditions of participation as described in N.J.A.C. 10:52, Hospital Services Manual; or
7. An ophthalmologist, optometrist, optician and ocularist practicing in another state who are duly licensed or meet the requirements of the state in which they are practicing with regard to dispensing optical appliances.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of HealthStart shall be to provide comprehensive maternity and child health care services for all pregnant women (including those determined to be presumptively eligible) and for children (under two years of age) in the State of New Jersey who are eligible for Medicaid benefits.