New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 52 - HOSPITAL SERVICES MANUAL
Subchapter 10 - CENTERS FOR MEDICARE & MEDICAID SERVICES HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) FOR HOSPITAL OUTPATIENT LABORATORY SERVICES
Section 10:52-10.3 - HCPCS Code Numbers, Procedure Description and Maximum Fee Schedule; Pathology/Laboratory (Codes and Narratives Not Found in CPT)

Universal Citation: NJ Admin Code 10:52-10.3
Current through Register Vol. 56, No. 18, September 16, 2024

PATHOLOGY/LABORATORY
HCPCSMaximum Fee
INDCodeMODProcedure DescriptionAllowance
G0027Semen analysis; presence2.40
and/or motility of sperm
excluding Huhner test
G0123Screening cytopathology,23.50
cervical or vaginal, thin
prep, auto
G0141Screening cytopathology10.00
smears, cervical or vaginal
performed by automated
system, with manual
rescreening requiring
interpretation by physician
G0306Complete CBC, automated5.00
(HGB, HCT, RBC, WBC, without
platelet count) and automated
WBC differential count
G0307Complete CBC, automated4.80
(HGB, HCT, RBC, WBC, without
platelet count)
G0328Colorectal cancer7.00
screening; fecal-occult blood
test, immunoassay, 1-3
simultaneous determinations
J0886Injection, Epoetin Alpha,13.31
1000 units (for ESRD patients
on dialysis)
P3000Screening Papanicolaou6.00
smear, cervical or vaginal,
up to three smears; by
technician under physician
supervision
P3001Requiring interpretation6.00
by physician
P9010Blood transfusion, wholeS.C.C.
blood (per unit)
P9011Blood transfusion, splitS.C.C.
unit, (specify amount)
P9012Cryopreipitate, each unitS.C.C.
P9016Leukocyte poor blood, eachS.C.C.
unit
P9017Fresh frozen plasma,S.C.C.
single
P9019Platelets, each unitS.C.C.
P9020Platelet rich plasma, eachS.C.C.
unit
P9021Red blood cells, each unitS.C.C.
P9022Red blood cells, washed,S.C.C.
each unit
P9023Plasma, pooled multiple,S.C.C.
donor solvent/detergent
treated, frozen, each unit
P9031Platelets, leukocytesS.C.C.
reduced, each unit
P9032Platelets, irradiated,S.C.C.
each unit
P9033Platelets, leukocytesS.C.C.
reduced, irradiated, each
unit
P9034Platelets, pheresis, eachS.C.C.
unit
P9035Platelets, pheresis,S.C.C.
leukocytes reduced, each unit
P9036Platelets, pheresis,S.C.C.
irradiated, each unit
P9037Platelets, pheresis,S.C.C.
leukocytes reduced,
irradiated, each unit
P9038Red blood cells,S.C.C.
irradiated, each unit
P9039Red blood cells,S.C.C.
deglycerolized, each unit
P9040Red blood cells,S.C.C.
leukocytes reduced,
irradiated, each unit
P9041Infusion, albumin (human),S.C.C.
5%, 50ml
P9043Infusion, plasma proteinS.C.C.
fraction (human), 5%, 50ml
P9044Plasma, cryoprecipitateS.C.C.
reduced, each unit
P9045Infusion, albumin (human),S.C.C.
5%, 250 ml
P9046Infusion, albumin (human),S.C.C.
25%, 20ml
P9047Infusion, albumin (human)S.C.C.
25%, 50ml
P9051Whole blood or red bloodS.C.C.
cells, leukocytes reduced,
cmv-negative, each unit
P9052Platelets, hla-matchedS.C.C.
leukocytes reduced,
apheresis/pheresis, each unit
P9053Platelets, pheresis,S.C.C.
leukocytes, reduced,
cmv-negative, irradiated each
unit
P9056Whole blood, leukocytesS.C.C.
reduced, irradiated, each
unit
P9058Red blood cells,S.C.C.
leukocytes reduced, each unit
P9060Fresh frozen plasma, donorS.C.C.
retested, each unit
P9604Prorated trip charge1.38
P9612Catheterization for1.80
collection of urine; all
places of service
P9615Catheterization for1.80
collection of (urine)
specimen(s), (multiple)
patients
QUALIFIER: This service is
reimbursable at a fixed rate
or at the amount of the
hospital charge (whichever is
less) per specimen type, per
patient encounter, regardless
of the number of patient
encounters per day.
Q0111Wet mount, including2.40
preparations of vaginal,
cervical or skin specimens
Q0112All potassium hydroxide2.40
(KOH) preparations
Q0113Pinworm examination5.10
Q0114Fern test9.60
Q0115Post-coital direct,12.33
qualitative examinations of
vaginal or cervical mucous
Q4081Injection, epoetin alfa,1.33
100 units (for ESRD on
dialysis)

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