New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 9 - HEALTH CARE FINANCING ADMINISTRATION (HCFA) COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:54-9.8 - HCPCS Procedure Codes with Qualifiers (except for Pathology/Laboratory)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following is a list of Level I HCPCS procedure codes with their associated qualifiers (except for Pathology and Laboratory procedure codes). Providers are to recognize the requirements inherent in billing each of the HCPCS. The qualifiers related to Pathology/Laboratory Services are located in the next section in 10:54-9.9. FOR A LISTING OF QUALIFIERS FOR THE EVALUATION AND MANAGEMENT PROCEDURE CODES, SEE (e) OF THIS SUBCHAPTER.
Code
Narrative
10040
Acne surgery (e.g. marsupialization, opening or removal of
multiple milia, comedones, cysts, pustules)
QUALIFIER: This code is limited to severe acne; for less severe
acne, utilize procedure codes for routine office visit. Excision
must involve the use of a scalpel and an expresser but not an
expresser alone.
11975
Insertion, implantable contraceptive capsules.
QUALIFIER: The maximum fee allowance is reimbursed for the
insertion or reinsertion of the "Norplant System" (six
levonorgestrel implants) and the post insertion visit when
provided in a hospital setting, when the physician bills for the
service. When using this procedure code, the physician will not
be reimbursed for the cost of the kit. The supplier of the kit
to the physician will be reimbursed directly for the cost of the
kit.
11975 22
Insertion, implantable contraceptive capsules.
QUALIFIER: The maximum fee allowance is reimbursed includes the
cost of the kit supplied to the physician, the insertion of the
"Norplant System" (six levonorgestrel implants) and the post
insertion visit. NOTE: The "22" modifier indicates the inclusion
of the cost of the kit.
11976
Removal of implantable contraceptive capsules.
QUALIFIER: The maximum fee allowance is reimbursed for the
removal of the "Norplant System" (six levonorgestrel implants)
and for the post removal visit.
11977
Removal of implantable contraceptive capsules.
QUALIFIER: The maximum fee allowance is reimbursed for the
removal of the "Norplant System" (six levonorgestrel implants).
11977 22
Removal with reinsertion, implantable contraceptive capsules.
QUALIFIER: The maximum fee allowance is reimbursed for the
removal and reinsertion of the "Norplant System" (six
levonorgestrel implants) and for the post removal/reinsertion
visit. NOTE: Modifier "22" indicates that the billing includes
the cost of the NPS kit.
36510
Catheterization of umbilical vein for diagnosis or therapy;
newborn.
QUALIFIER: May be used in addition to a Hospital Inpatient
Services or Inpatient Consultation procedure codes, if
applicable, but not in addition to Critical Care or Prolonged
Detention procedure codes.
36660
Catheterization of umbilical artery, newborn, for diagnosis or
therapy.
QUALIFIER: May be used in addition to a Hospital Inpatient
Services or Inpatient Consultation procedure codes, if
applicable, but not in addition to Critical Care or Prolonged
Detention procedure codes.
(b) Diagnostic endoscopy: The following are the qualifiers for HCPCS procedure codes for diagnostic endoscopic procedure codes.
1. Respiratory System (CPT codes 30000-32999)
31520
Laryngoscopy direct, with or without tracheoscopy; diagnostic
newborn.
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
31525
Laryngoscopy direct, with or without tracheoscopy; diagnostic
except newborn.
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
31575
Laryngoscopy, flexible fiberoptic; diagnostic
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
31615
Tracheobronchoscopy through established tracheostomy incision.
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
31622
Diagnostic (flexible or rigid) with or without all washing or
brushing.
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
2. Hemic and Lymphatic systems (CPT codes 38100-39599)
39400 22
Mediastinoscopy with biopsy
QUALIFIER: Multiple surgery pricing applies.
3. Digestive system (CPT codes 40490-49999)
i. Upper gastrointestinal system
43200
Esophagoscope, rigid or flexible; diagnostic, with or without
removal of foreign body
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
43234
Upper gastrointestinal endoscopy simple primary examination
(e.g. with small diameter flexibile fiberscope)
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
43235
Upper gastrointestinal endoscopy including esophagus, stomach
and either the duodenum and/or jejunum, as appropriate; complex
diagnostic
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
ii. Lower gastrointestinal
45300
Proctosigmoidoscopy; diagnostic (separate procedure)
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
45330
Sigmoidoscopy, flexible fiberoptic; diagnostic
QUALIFIER: When combined with another endoscopic procedure, the
procedure may be reimbursed at the rate of the maximum fee
allowance of the procedure of the "deepest penetration".
46600
Anoscope: diagnostic (separate procedure)
QUALIFIER: This diagnostic endoscopy procedure has the least
penetration: (despite the "high" HCPCS number). When combined
with another endoscopic procedure in the same body system, the
reimbursement is at the rate of the maximum fee allowance of any
other procedure code that denotes the "deepest penetration".
iii. Biliary tract;
47550
Biliary endoscopy, intraoperative (kaleidoscope)
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
47552
Biliary endoscopy, intraoperative (kaleidoscope)
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
iv. Urinary system (CPT codes 50010-53899)
50951
Ureteral endoscopy through established ureterostomy, with or
without irrigation, instillation, or ureteropyelography,
exclusive of radiologic service
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
50970
Ureteral endoscopy through ureterotomy, with or without
irrigation, instillation, or ureteropyelography, exclusive of
radiologic service
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
52000
Cystourethroscopy (separate procedure)
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.
v. Female genital system (CPT codes 56000-58999)
57452
Colposcopy (vaginoscopy); (separate procedure)
QUALIFIER: When combined with another endoscopic procedure, each
procedure may be reimbursed at 100% of the maximum fee
allowance.