reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.3 - Provisions regarding surgery

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Specific requirements for surgery procedures may be found at 10:57-3.2(b).
1. Certain surgical procedures are carried out as an integral part of a total service and, as such, do not warrant a separate charge. When such a procedure is carried out as a separate entity not immediately related to other services, the provider may bill a value for Separate Procedure.
2. Complications or other circumstances requiring additional and unusual services concurrent with the procedure(s) or during the listed period of normal follow-up care, may warrant additional reimbursement on a fee-for-service basis.
3. When multiple or bilateral surgical procedures, which add significant time or complexity to patient care, are performed at the same operative session, the total reimbursement shall be the allowance of the primary procedure plus 50 percent of the allowance of the secondary procedures to a total maximum of 200 percent of the primary procedure unless otherwise specified in this section.
4. Anesthesia services rendered to his or her patient by the operating podiatrist are considered part of the surgical procedure and will not receive any additional reimbursement.
5. Reimbursement will be made for an assistant surgeon when the service is medically necessary and when a duly qualified surgical resident or house physician is unavailable, and when the primary procedure performed has a procedure code specialist fee of at least $ 142.00. The allowance permitted is a maximum of 15 percent of the listed specialist fee. The minimum payment is $ 27.00.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.4 - Radiology services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Specific requirements for radiology procedures may be found at 10:57-3.2(c).
1. Reimbursement will be made for the combined technical and professional component of the reimbursement for the procedure code notwithstanding any statement to the contrary in the narrative. It will be paid only to one provider and will not be broken down into its component parts.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.5 - Consultation policies

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A consultation is recognized for reimbursement only when performed by a specialist, as the term is defined at 10:57-1.3, who is recognized as such by this Program and the request has been made by or through the patient's attending physician or other licensed practitioner and the need for such a request would be consistent with good medical practice. Two types of consultation are recognized for reimbursement--comprehensive consultation and limited consultation.
(b) If a consultation is performed in an inpatient or outpatient setting and the patient is then transferred to the consultant's service during that course of illness, then the provider shall not bill for an initial visit if he or she bills for the consultation.
(c) If there is no referring physician, podiatrist or licensed practitioner, then an initial visit code should be billed instead of a consultation code.
(d) If the patient is seen for the same illness on repeated visits by the same consultant, these visits are considered routine visits or follow-up care visits and not consultations.
(e) Consultation codes will be declined in an office or residential health care facility setting if the consultation has been requested by or between members of the same group, shared health care facility or physicians, podiatrists and/or licensed practitioners sharing common records. A routine visit code is applicable under these circumstances.
(f) If a prior claim for comprehensive consultation visit has been made within the preceding 12 months, then a repeat claim for this code will be denied if made by the same physician/podiatrist, physician/podiatrist group, shared health care facility or physicians/podiatrists using a common record except in those instances where the consultation required the utilization of one hour or more of the podiatrist's personal time. Otherwise, limited consultation codes would be considered the applicable codes to utilize if their criteria are met.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.6 - Podiatric orthotic services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Payment will be allowed for orthotic services rendered by a podiatrist for his or her own patients with prior authorization (See 10:57-1.5 ).
(b) Services provided by a prosthetic and orthotic (P&O) facility must be billed directly to the program by the P&O facility, and not by the referring practitioner. (See N.J.A.C. 10:55, Prosthetic and Orthotic Services.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.7 - 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 the Centers for Medicare & Medicaid Services (CMS) in accordance with the Clinical Laboratory Improvement Act (CLIA) and ordered by a physician or other licensed practitioner, within the scope of his or her practice as defined by the laws of the State of New Jersey and/or of the state in which the practitioner practices.
(b) Clinical laboratory services are furnished by clinical laboratories and by physician office laboratories (POLs) that meet the CMS regulations pertaining to clinical laboratory services defined in the Clinical Laboratory Improvement Amendments Act (CLIA) of 1988; 1902(a)(9) of the Social Security Act; 42 U.S.C. 1396 a (a)(9); and as indicated at 10:61-1.2, the Medicaid/NJ FamilyCare program's Independent Clinical Laboratory Services chapter.
(c) All independent clinical laboratories and other entities performing clinical laboratory testing shall possess certification as required by CLIA 1988, and the New Jersey Department of Health rules found at N.J.A.C. 8:44 and 8:45.
(d) A podiatrist may claim reimbursement for clinical laboratory services performed for his or her own patients within his or her own office, subject to the following:
1. A podiatrist shall meet the conditions of the CLIA regulations before she or he may perform clinical laboratory testing for Medicaid recipients; and
2. The clinical laboratory tests shall be standard clinical laboratory procedures consistent with the podiatrist's CLIA certification, certificate of waiver or certificate of registration as an independent clinical laboratory.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.8 - Hospital outpatient department services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A hospital-based podiatrist 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.
1. A podiatrist practicing in the hospital outpatient department, whose reimbursement is not part of the hospital's cost, may bill fee-for-service independent of the hospital charges for professional service according to Medicare principles of reimbursement, if the arrangement with the hospital permits it.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.9 - Diagnostic radiology services

Current through Register Vol. 56, No. 14, July 15, 2024
Payment will be allowed for necessary radiological services by a podiatrist, subject to the limitations of his or her licensure. Routine X-rays for screening purposes shall not be reimbursed.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.10 - Multiple visits; out of office

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Podiatry services rendered in a residential or medical facility (that is, hospital, nursing home, or extended care facility) shall be based on referral by the attending physician.
(b) Multiple visits to patients in the same health facility or congregate living arrangement will be reimbursed on an out-of-office visit basis for the initial visit to each patient and on an office visit basis for each subsequent visit to each patient receiving services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.11 - Pharmaceutical; podiatrist administered drugs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare fee-for-service program shall reimburse podiatrists for certain approved drugs administered intradermally, subcutaneously, intra-muscularly, or intravenously in the office, home, or independent clinic setting according to the following reimbursement methodologies and the requirements of N.J.A.C. 10:51.
1. Podiatrist-administered medications shall be reimbursed directly to the podiatrist under certain situations. (See HCPCS, N.J.A.C. 10:57-3for a listing of HCPCS procedure codes.)
i. A "J" code may be billed in conjunction with an office, home, or independent clinic visit when the criteria for an office or home visit is met and the procedure code is for the method of drug administration.
ii. The Division has assigned HCPCS procedure codes and Medicaid/NJ FamilyCare maximum fee allowances to certain, selected drugs for which reimbursement to the podiatrist is based on the Average Wholesale Price (AWP) of a single dose of an injectable drug, or the podiatrist's acquisition cost, whichever is less.
iii. Unless otherwise indicated in N.J.A.C. 10:57-2, the Medicaid/NJ FamilyCare maximum fee allowance is determined based on the AWP per unit which equals one cubic centimeter (cc) or milliliter (ml) of drug volume for each unit. For drug vials with a volume equal to one cubic centimeter (cc) or milliliter (ml), the Medicaid/NJ FamilyCare maximum fee allowance shall be based on the cost per vial.
iv. A visit for the sole purpose of an injection is reimbursable as an injection and not as an office visit plus an injection. On the other hand, if the criteria of an office or home visit are met, an injection may, if medically indicated, be considered as an add-on to the visit. The drug administered must be consistent with the diagnosis and conform to accepted medical and pharmacological principles in respect to dosage frequency and route of administration.
v. No reimbursement will be made for an injection given as a preoperative medication or as a local anesthetic that is part of an operative or surgical procedure, since this injection would normally be included in the prescribed fee for such a procedure.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.12 - Pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
All covered pharmaceutical services provided under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall be provided to New Jersey Medicaid/NJ FamilyCare fee-for-service beneficiaries within the scope of N.J.A.C. 10:49, Administration, and 10:51, Pharmaceutical Services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:57-2.13 - Medical exception process (MEP)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For pharmacy claims with service dates on or after September 1, 1999, which exceed Prospective Drug Use Review (PDUR) standards recommended by the New Jersey Drug Utilization Review Board (NJ DURB) and approved by the Commissioners of DHS and DOH, the Division of Medical Assistance and Health Services has established a Medical Exception Process (MEP). See N.J.A.C. 10:51-2.23for more information on the PDUR program.
(b) The medical exception process shall be administered by a contractor, referred to as the MEP contractor, under contract with the Department of Human Services.
(c) The medical exception process shall apply to all pharmacy claims, regardless of claim media, unless there is a recommended exemption by the NJ DURB that has been approved by the Commissioners of DHS and DOH, in accordance with the rules of those Departments.
(d) The medical exception process (MEP) is as follows:
1. The MEP contractor shall contact prescribers of conflicting drug therapies, or drug therapies which exceed established PDUR standards, to request written justification to determine medical necessity for continued drug utilization.
i. The MEP contractor shall send a Prescriber Notification Letter which includes, but may not be limited to, the beneficiary name, HSP identification number, dispense date, drug quantity, drug description. The prescriber shall be requested to provide the reason for medical exception, diagnosis, expected duration of therapy, and expiration date for medical exception.
ii. The prescriber shall provide information requested on the Prescriber Notification to the MEP contractor.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 3 - CENTERS FOR MEDICARE AND MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:57-3.1 - Introduction to the HCPCS procedure coding system

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid and NJ FamilyCare programs use the Federal Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act, of 1996, 42 USC §
										1320d et seq., and incorporated herein by reference, as amended and supplemented, and as published by PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010. Revisions to the Healthcare Common Procedure Coding System made by CMS (code additions, code deletions, and replacement codes) will be reflected in this subchapter through publication of a notice of administrative change in the New Jersey Register. Revisions to existing reimbursement amounts specified by the Department and specification of new reimbursement amounts for new codes will be made by rulemaking in accordance with the Administrative Procedure Act, 52:14B-1 et seq. HCPCS follows the American Medical Association's Physician's Current Procedural Terminology CPT architecture, employing a five-position code and as many as two two-position modifiers. Unlike the CPT numeric design, the CMS-assigned codes and modifiers contain alphabetic characters. Because of copyright restrictions, the CPT procedure narratives for Level I codes are not included in this manual, but are incorporated herein by reference, as amended and supplemented. An updated copy of the CPT (Level I) codes may be obtained from the American Medical Association, P.O. Box 10950, Chicago, IL 60610, or by accessing
http://www.ama-assn.org
. An updated copy of the HCPCS (Level II) codes may be obtained by accessing the HCPCS website at
http://www.cms.hhs.gov/medicare/hcpcs
or by contacting PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010.
(b) HCPCS has been developed as a two-level coding system, as follows:
1. Level I codes: Narratives for these codes are found in CPT, which is incorporated herein by reference, as amended and supplemented. The codes are adapted from CPT for use primarily by physicians, podiatrists, optometrists, certified nurse-midwives, certified nurse practitioners and clinical nurse specialists, independent clinics and independent laboratories. Level I procedure codes, and fees for each, for which podiatrists may bill, can be found at 10:57-3.2.
2. Level II codes: These codes are assigned by CMS for physician and non-physician services which are not in CPT. Narratives for these codes, and the fees for each, can be found at 10:57-3.3.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
FISCAL AGENT BILLING SUPPLEMENT
AGENCY NOTE: The Fiscal Agent Billing Supplement is appended as a part of this chapter but is not reproduced in the New Jersey Administrative Code. When revisions are made to the Fiscal Agent Billing Supplement, replacement pages will be distributed to providers and copies will be filed with the Office of Administrative Law. For a copy of the Fiscal Agent Billing Supplement, write to:
DXC Technology
PO Box 4801
Trenton, New Jersey 08619-4801
or contact
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, New Jersey 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this chapter is to provide the standards for approval of certified nurse midwives as independent providers of services, within their licensed scope of practice and in accordance with the requirements of N.J.A.C. 13:35-2A, to New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service beneficiaries.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.2 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The rules in this chapter govern reimbursement made directly to a nurse midwife provider. Reimbursement shall not be made to a certified nurse midwife unless the nurse midwife has been approved as a Medicaid/NJ FamilyCare provider, in accordance with the provisions of this chapter and applicable provisions of N.J.A.C. 10:49.
(b) Reimbursement may be made for services provided by a certified nurse midwife employed by a physician or physician/practitioner group (N.J.A.C. 10:54), by an independent clinic (N.J.A.C. 10:66), or by a hospital (N.J.A.C. 10:52), in accordance with the applicable rules.
(c) The rules in this chapter govern the provision of fee-for-service nurse midwifery services provided to Medicaid/NJ FamilyCare-Plan A fee-for-service beneficiaries. Nurse midwifery services provided to beneficiaries who are enrolled in a managed care organization (MCO) shall be governed by the individual MCO contract.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.4 - Application for provider status; certified nurse midwife

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any nurse midwife may apply to the New Jersey Medicaid/NJ FamilyCare programs for approval as a Medicaid/NJ FamilyCare provider, if he or she:
1. Is a registered professional nurse licensed by the New Jersey State Board of Nursing;
2. Is certified by the American College of Nurse Midwives (ACNM) or the American College of Nurse Midwives Certification Council;
3. Shows evidence of continuing competency, as required by the ACNM; and
4. Is registered as a certified nurse midwife by the New Jersey State Board of Medical Examiners.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.5 - Application for provider status; HealthStart

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A certified nurse midwife who is a Medicaid/NJ FamilyCare provider may also become a HealthStart Comprehensive Maternity Care or HealthStart Maternity Medical Care services provider.
(b) In order to participate as a provider of HealthStart services, the CNM practicing independently or as part of a group shall be a Medicaid/NJ FamilyCare provider and shall meet the HealthStart requirements specified at N.J.A.C. 10:66-3 and in this chapter. A HealthStart provider shall have a valid HealthStart Provider Certificate.
1. An application for a HealthStart Provider Certificate is available from the Medicaid/NJ FamilyCare fiscal agent:
Gainwell Technologies
Provider Enrollment
Mail Code #9
PO Box 4804
Trenton, NJ 08650-4804
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.6 - Application for provider status; birth centers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A birth center shall enroll as a CNM provider in order to receive reimbursement for the use of the facility for labor and delivery services provided at the center.
(b) The birth center shall be licensed by the Department of Health in accordance with the provisions at N.J.A.C. 8:43A-28.
(c) In order to receive reimbursement for professional services provided by a CNM employed by the birth center, the birth center shall enroll as a CNM provider and the CNM employed by the birth center shall meet the provider requirements in 10:58-1.4(a).
(d) When a CNM not employed by a birth center provides professional services at the birth center as an independent provider, the CNM shall bill Medicaid/NJ FamilyCare directly for those professional services.
(e) The birth center shall complete the Medicaid/NJ FamilyCare Provider Application (FD-20), the Provider Agreement (FD-62) , and the Ownership and Control Interest and Disclosure Statement (CMS-1513).
1. The birth center shall include with the application a copy of its license, a list of all the CNMs employed by the center, together with their CNM Medicaid/NJ FamilyCare provider numbers, and copies of the CNMs' licenses. The application and all attachments shall be submitted to: Gainwell Technologies Provider Enrollment Mail Code #9 PO Box 4804 Trenton, NJ 08650-4804
2. Each CNM employed by the birth center shall have a provider servicing number. The birth center shall report this number when billing Medicaid/NJ FamilyCare for CNM services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.7 - Basis of reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursement for certified nurse midwifery services shall be based upon the provider's usual and customary charge or the allowance determined by the Commissioner of the Department of Human Services and contained in N.J.A.C. 10:58-3, whichever is less.
(b) A certified nurse midwife who is approved as a provider of services by the New Jersey Medicaid or the NJ FamilyCare programs, and who practices independently and not as part of a physician group or other organized medical care entity, may be directly reimbursed by the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service programs, in accordance with the provisions of this chapter.
(c) The basis for reimbursement of services provided in a birth center is as follows:
1. The birth center shall receive a facility fee of $ 1,300, exclusive of laboratory, drugs, and professional fees, for beneficiaries attended on-site during labor and delivery.
2. A birth center shall receive a facility fee of $ 500.00, exclusive of laboratory, drugs, and professional fees, for beneficiaries who are admitted to the birth center in labor but subsequently transferred to a hospital.
3. The HCPCS codes for billing for birth center facility services are described in 10:58-3.5(g).
4. A birth center shall be reimbursed for professional CNM services provided by a CNM employed by the birth center in accordance with 10:58-1.6(a). The birth center shall not be reimbursed for professional CNM services provided by a CNM who is an independent provider.
5. A physician who provides professional services in a birth center shall bill for his or her services in accordance with 10:54-4.33 in order to receive reimbursement for professional services.
6. A birth center billing for laboratory services shall meet all requirements found in 10:58-2.9 through 2.13.
7. A birth center billing for medications shall meet all requirements found in 10:58-2.17.
8. A birth center may bill for certain injections relative to maternity care or provided to the newborn at the time of delivery, in accordance with 10:58-3.5(c).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.8 - 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 services are set forth at N.J.A.C. 10:49-9.
(b) The 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 prenatal care, preventive care or for family planning services.
1. An office visit is defined as a face-to-face contact with a medical professional which meets the requirements of this chapter and which allows the certified nurse midwife to request reimbursement.
2. Office visits include certified nurse midwife services provided in the office, patient's home, birth center, or any other site, except hospital.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.9 - Recordkeeping; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The certified nurse midwife shall keep such legible, individual records as are necessary to fully disclose the kind and extent of services provided, and the medical necessity for those services.
(b) Minimum documentation requirements for services performed by the certified nurse midwife shall include a clinical note or a progress note in the clinical record for each visit, which supports the procedure code or codes to be claimed. This information shall be available upon the request of the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service programs or their agents.
(c) Documentation of services performed by the CNM shall include, at a minimum:
1. The date of service;
2. The name of the patient;
3. The patient complaint, reason for visit;
4. Subjective findings;
5. Objective findings;
6. An assessment;
7. A plan of care, including, but not limited to, any orders for laboratory work, prescriptions for medications;
8. The signature of the practitioner rendering the service; and
9. Other documentation appropriate to the procedure code being billed. See N.J.A.C. 10:58-3, HCPCS Codes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.10 - Recordkeeping; initial visit

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to receive reimbursement for an initial visit, the following documentation, at a minimum, shall be on the record, regardless of the setting where the examination was performed:
1. The chief complaint(s);
2. A complete history of the present illness and related systemic review-- including recordings of pertinent negative findings;
3. A pertinent past medical history;
4. A pertinent family history;
5. A full physical examination pertaining to, but not limited to, the history of the present illness and including recordings of pertinent negative findings; and
6. The working diagnoses and treatment plan including ancillary services and drugs ordered.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.11 - Recordkeeping; routine or follow-up visits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to document the record for reimbursement purposes, the progress note for routine office visits or follow-up care visits shall include the following:
1. In an office:
i. The purpose of the visit;
ii. Pertinent history obtained;
iii. Pertinent physical findings, including pertinent negative physical findings based on (a)i and ii above;
iv. The procedures, if any, with results;
v. Laboratory, X-ray, EKG, etc., ordered with results; and
vi. The diagnosis(es).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.12 - Recordkeeping; hospital inpatient stay

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To qualify as documentation that the service was rendered by the practitioner during a hospital inpatient stay, the medical record shall contain the CNM's notes, indicating that the practitioner personally:
1. Reviewed the patient's medical history with the patient and/or his or her family, depending upon the medical situation;
2. Performed an examination as appropriate;
3. Confirmed or revised the diagnosis; and
4. Visited and examined the patient on the days for which a claim for reimbursement is made.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.13 - Recordkeeping; preventive medicine services; annual health maintenance examination

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For individuals under 21 years of age, the following shall be performed and documented in the beneficiary's record:
1. A history (complete initial for new patient, interval for established patient) including past medical history, family history, social history, and systemic review;
2. A developmental and nutritional assessment;
3. A complete, unclothed, physical examination to also include the following:
i. Measurements, including: height and weight; head circumference to 25 months; blood pressure for children age three years or older; and
ii. Vision and hearing screening;
4. An assessment and administration of immunizations appropriate for age and need, as determined by medical practice and professional medical judgment, in accordance with 42 U.S.C. §
											1396s and N.J.A.C. 10:58-3;
5. Provisions for further diagnosis, treatment and follow-up, by referral if necessary, of all correctable abnormalities uncovered or suspected;
6. Referral to a dentist for children age three years or older;
7. Laboratory procedures performed or referred if medically necessary. Recommendations are:
i. Hemoglobin/Hematocrit: 10 to 12 years;
ii. Urinalysis: 13 to 18 years;
iii. Tuberculin test (Mantoux) annually;
iv. Lead screening using blood level determinations shall be performed between six and 12 months, at two years of age, and annually up to six years of age. At all other visits, screening shall consist of verbal risk assessment and blood lead level test, as indicated; and
v. Other appropriate screening procedures, if medically necessary, (for example: blood cholesterol, test for ova and parasites, STD);
8. Health education and anticipatory guidance; and
9. An offer of social service assistance; and, if requested, referral to a county board of social services (CBOSS).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.14 - Recordkeeping; home visit or house call

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The record and documentation of a home visit or house call shall become part of the office progress notes and shall include, as appropriate, the following information:
1. The purpose of the visit;
2. The pertinent history obtained;
3. Pertinent physical findings, including pertinent negative physical findings based on (a)1 and 2 above;
4. The procedures, if any performed, with results;
5. Laboratory, X-ray, ECG, etc., ordered with results; and
6. The diagnosis(es) plus treatment plan status relative to present or pre-existing illness(es) plus pertinent recommendations and actions.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58-1.15 - Recordkeeping requirements for birth center services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medical records maintained by a birth center for the maternity services shall include, but not be limited to:
1. Patient identification;
2. An initial medical history, results of physical examination, and diagnosis;
3. Progress notes for each visit, which shall include interim history, physical findings, and disposition;
4. Reports of laboratory and other diagnostic studies, and consultation;
5. Any allergies and abnormal drug reactions;
6. A report of the delivery process;
7. The status and condition of the newborn;
8. Documentation of properly executed informed consent of each woman enrolling in a birth center for treatment; and
9. A discharge diagnosis.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.1 - Evaluation and management services (HCPCS)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Evaluation and management services HCPCS procedure codes are used to indicate certain services performed in a CNM's independent practice.
(b) Reimbursement for an initial office visit will be disallowed if a preventive medicine service visit, EPSDT examination visit or office consultation were billed within a 12-month period by the same practitioner, group of practitioners, or shared health care facility sharing a common record.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.2 - Evaluation and management: initial visits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For office visits and for other care apart from inpatient hospital, CNMs shall bill for an initial visit only once for a specific patient, subject to the exceptions contained in (b) below. When a shared health care facility, a group of physicians and/or other practitioners (CNMs) share a common record, the Division will reimburse only one initial visit. Further encounters with that patient will be billed and reimbursed by means of "established patient" codes. (See 10:58-3.1 through 3.5.)
(b) In the inpatient hospital setting, the initial visit concept still applies for reimbursement purposes, except that subsequent readmissions to the same facility may be designated as initial visits as long as a time interval of 30 days or more has elapsed between admissions.
(c) An initial hospital visit will be disallowed to the same practitioner, group of practitioners, shared health care facility, or practitioners sharing a common record who submit a claim for a consultation and transfer the patient to their service.
(d) In order to use the HCPCS procedure code to bill for an initial visit, the CNM shall provide the minimal documentation in the record regardless of the setting where the examination was performed. See 10:58-1.8(c).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.3 - Evaluation and management: office or other outpatient services (established patient); or subsequent hospital care

Current through Register Vol. 56, No. 14, July 15, 2024
Office or other outpatient service, or subsequent hospital care visits shall conform to the CPT description of provider involvement and time. The setting could be office or hospital. The documentation requirements for these visits are found in 10:58-1.9.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.4 - Evaluation and management: preventive medicine

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In the absence of patient complaints, the procedure codes identified as preventive medicine services shall be used for adults and for children.
(b) Preventive medicine services codes (new patient) are comparable, in respect to reimbursement level, to an initial visit and, therefore, shall only be billed once per patient, per year. These codes shall be denied when the beneficiary is seen by the same practitioner, group of practitioners, or involves a shared health care facility sharing a common record. Preventive visits (established patient) for adults shall be considered an annual health maintenance visit.
(c) Requirements for preventive medicine services, the annual health maintenance examination, for new or established patients under the age of 21 are as follows:
1. These codes are not allowable for payment when used following an EPSDT examination performed within the preceding 12 months for a child older than two years of age; and
2. Preventive medicine codes may be used in accordance with the periodicity schedule of preventive visits recommended by the American Academy of Pediatrics. (See 10:58-2.8 through 2.12.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.5 - Evaluation and management: consultations requested by CNMs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A consultation shall be reimbursed by the New Jersey Medicaid/NJ FamilyCare fee-for-service programs when performed by a physician specialist (other than her collaborating physician) recognized as such by the Medicaid/NJ FamilyCare programs and when the request is made by or through the patient's CNM. The need for such a request shall be consistent with good medical practice.
(b) When the CNM needs to refer the patient(s) for consultation or for other services, the provider of the consultation or other service shall bill the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service programs directly and shall be reimbursed directly for the consultation or referred service.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.6 - Evaluation and management: CNM home services and house calls

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The home services recognized as "house calls" refer to a practitioner visit to an individual who would be too ill to go to a practitioner's office and/or is "home bound," as determined by the attending physician, due to his or her physical condition. CNMs shall be reimbursed for house calls.
(b) For purposes of Medicaid/NJ FamilyCare-Plan A fee-for-service reimbursement, "home visits" apply when the provider visits Medicaid/NJ FamilyCare-Plan A fee-for-service beneficiaries who do not qualify as "home bound." CNMs are not reimbursed for home visits.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.7 - Evaluation and management: emergency department and inpatient hospital services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When a practitioner sees the patient in the emergency room instead of his or her office, the practitioner shall use the same codes for the visit that would have been used if seen in the practitioner's office. Records of that visit shall become part of the notes in the office chart.
(b) When patients are seen by hospital-based emergency room practitioners who are eligible to bill the Medicaid/NJ FamilyCare-Plan A fee-for-service programs, the appropriate HCPCS code is used. These "visit" codes are listed at 10:58-3.2.
(c) Critical care/prolonged services shall be covered when the patient's situation requires constant practitioner attendance which is given by the practitioner to the exclusion of her other patients and duties, and therefore represents what is beyond the usual service for the practitioner.
1. The critical care/prolonged services code shall not apply to monitoring pregnant women in labor.
2. Critical care/prolonged service shall be documented in the applicable records, as defined by the setting. The records shall show, in the practitioner's handwriting, the time of onset and time of completion of the service. Settings that are applicable are the office, hospital, or home.
3. The reimbursement for the "critical care" or prolonged services utilizes the time parameter, and is all-inclusive, meaning that it shall be the only payment for care provided by the practitioner to the patient at that time. The specific procedures performed during that patient encounter shall not be reimbursed in addition to the "critical care/prolonged services" payment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.8 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT); general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is a comprehensive health program for Medicaid/NJ FamilyCare beneficiaries from birth through 20 years of age. The goal of the program is to assess the beneficiary's 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 10:54-1.5, concerning certification of physician services.
(c) 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.
(d) EPSDT services shall include the following:
1. 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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.9 - Clinical laboratory services; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Clinical laboratory services shall be furnished by clinical laboratories and by provider office laboratories (POLs) that meet the Centers for Medicare and Medicaid Services (CMS) regulations pertaining to clinical laboratory services (Section 1902(a)9 of the Social Security Act; 42 U.S.C. §
										1396(a)9; 42 CFR 440.30 and 493) defined in the Clinical Laboratory Improvement Amendments (CLIA) of 1988 ( P.L. 100-518 ), and as indicated at N.J.A.C. 10:61-2.1, the Medicaid/NJ FamilyCare programs' Independent Clinical Laboratory Services Manual (N.J.A.C. 10:61) and N.J.A.C. 8:44 and 8:45.
(b) All independent clinical laboratories and other entities performing clinical laboratory testing for Medicaid/NJ FamilyCare-Plan A fee-for-service beneficiaries must meet the requirements of the Clinical Laboratory Improvement Amendments (CLIA) of 1988. These requirements include that the provider must have one of the following certificates; as required by 42 C.F.R. 493:
1. A certificate of waiver;
2. A certificate of compliance;
3. A registration certificate;
4. A certificate for provider-performed microscopy (PPM) procedures;
5. A certificate of accreditation, and a registration certificate or a certificate of compliance; or
6. Be CLIA exempt due to accreditation by a private nonprofit accreditation organization or exempted under an approved state laboratory program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.10 - Clinical laboratory services provided by a CNM

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A CNM may claim reimbursement for clinical laboratory services performed for his or her own patients within his or her own office, except when provided in a birth center. Laboratory services provided in a birth center shall be billed to Medicaid/NJ FamilyCare-Plan A fee-for-service programs by the center.
1. A CNM shall meet the conditions of the CLIA regulations before she or he may perform clinical laboratory testing for Medicaid/NJ FamilyCare-Plan A fee-for-service beneficiaries; and
2. The clinical laboratory tests shall be standard clinical laboratory procedures consistent with the CNM's CLIA certification, certificate of waiver or certificate of registration.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.11 - Clinical laboratory services; venipuncture

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When any part of the clinical laboratory test(s) is performed on site, the venipuncture is not reimbursable as a separate procedure: its cost is included within the reimbursement for the laboratory procedure. Venipuncture is reimbursable if the total specimen is referred to the independent clinical laboratory.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.12 - Clinical laboratory services; CNM referral to independent laboratory

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When the CNM refers a laboratory test to an independent clinical reference laboratory:
1. The clinical reference laboratory shall be certified under CLIA requirements to perform the required laboratory test(s) (see Section 1902(a)9 of the Social Security Act; 42 U.S.C. 1396 a(a)9; 42 C.F.R. 440.30, 493 );
2. The clinical laboratory shall be licensed by the New Jersey State Department of Health in accordance with N.J.A.C. 8:44 and 8:45, or comparable agency in the state in which the laboratory is located; and
3. The clinical laboratory shall be approved for participation as an independent laboratory provider by the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service programs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.13 - Clinical laboratory services; rebates

Current through Register Vol. 56, No. 14, July 15, 2024
Rebates by reference laboratories, service laboratories, physicians or other utilizers or providers of laboratory services are prohibited under the New Jersey Medicaid/NJ FamilyCare programs. This refers to rebates in the form of refunds, discounts or kickbacks, whether in the form of money, supplies, equipment, or other things of value. This provision prohibits laboratories from renting space from or providing personnel or other considerations to a physician or other practitioner whether or not a rebate is involved.