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)

(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.

(b) Diagnostic endoscopy: The following are the qualifiers for HCPCS procedure codes for diagnostic endoscopic procedure codes.

(c) HCPCS Code Qualifiers

(d) Magnetic Resonance Imaging (MRI) Diagnostic Services:

(e) The following statements and qualifiers apply to the "Evaluation and Management" procedure codes (HCPCS 99201-99499).

OFFICE OR OTHER OUTPATIENT SERVICES--NEW PATIENT; HOSPITAL INPATIENT SERVICES--INITIAL HOSPITAL CARE; NURSING FACILITY SERVICES--COMPREHENSIVE NURSING FACILITY ASSESSMENTS; AND DOMICILIARY, REST HOME, OR CUSTODIAL CARE SERVICES--NEW PATIENT

(Excludes Preventive Health Care for patients through 20 years of age.)

OFFICE OR OTHER OUTPATIENT SERVICES--ESTABLISHED PATIENT; HOSPITAL INPATIENT SERVICES--SUBSEQUENT HOSPITAL CARE; NURSING FACILITY SERVICES--SUBSEQUENT NURSING FACILITY CARE; AND DOMICILIARY, REST HOME OR CUSTODIAL CARE SERVICES--ESTABLISHED PATIENT

(Excludes Preventive Health Care for patients through 20 years of age.)

1. 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 may not bill for an Initial Visit if he/she bills for the consultation.

2. If there is no referring physician, then an Initial Visit code should be used instead of a consultation code.

3. 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.

4. 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 sharing common records. A routine visit code is applicable under these circumstances.

5. 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, physician group, shared health care facility or physicians using a common record except in those instances where the consultation required the utilization of one hour or more of the physician's personal time. Otherwise, applicable codes would be limited consultation code if their criteria are met.

1. History (complete initial for new patient, interval for established patient) including past medical history, family history, social history, and systemic review.

2. Developmental and nutritional assessment.

3. Complete, unclothed, physical examination to include also the following:

4. Assessment and administration of immunizations appropriate for age and need.

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 3 or older.

7. Laboratory procedures performed or referred if medically necessary. Recommendations are:

8. Health education and anticipatory guidance.

9. Offer of social service assistance; and, if requested, referral to County Welfare Agency.

10. Referral for further diagnosis and treatment or follow-up of all correctable abnormalities, uncovered or suspected. Referral may be made to the provider conducting the screening examination or to another provider, as appropriate.

11. Referral to the Special Supplemental Food program for Women's Infants and Children (WIC) is required for children under 5 years of age and for pregnant or lactating women.

Note: Preventive medicine services codes (new patient) 99382, 99383, 99384, 99385, 99386, and 99387 are comparable to an initial visit and, therefore, may only be billed once. Future use of these codes will be denied when the recipient is seen by the same physician, group of physicians, or involves a shared health care facility, group of physicians sharing a common record. These codes will also be automatically denied for payment when used following an EPSDT examination (procedure code W9820) performed within the preceding 12 months.

Preventive medicine services codes (established patient) 99392, 99393, 99394, 99395, 99396 and 99397 may be used only once in a 12-month period for any individual over 2 years of age. For well-child care provided to children under the age of two, it is suggested that the provider bill for an EPSDT examination.

Preventive medicine services code 99391 and 99392 may be used up to 5 times during the patient's first year of life and up to 3 times during the patient's second year of life respectively, in accordance with the periodicity schedule of preventive visits recommended by the American Academy of Pediatrics. These codes do not apply to children under 2 years of age participating in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) or Pediatric HealthStart program. EPSDT and the Pediatric HealthStart providers bill for these services using the program appropriate codes W9060-W9068 or W9060WT-W9068WT.

(f) The following statements apply to HCPCS procedure codes which require medical justification.

(g) Cosmetic surgery: The following are a list of procedure codes that are considered by Medicaid as cosmetic surgical procedures and unless prior authorized as a result of being considered medically necessary, are not reimbursed.

(h) Physician Administered Drugs

(i) Hepatitis B Vaccine: Coverage is available for post exposure prophylaxis and for vaccination of individuals in selected high risk groups, regardless of age, in accordance with the criteria defined by the CDC. In all such cases, the need for this vaccination must be fully documented in the recipient's medical record. In order to facilitate reimbursement for Hepatitis B immunoprophylaxis for high risk individuals, manufacturer, age, and dose specific procedure codes have been developed for use by physicians and independent clinics providing this service.

EXCEPTION: The New Jersey Medicaid program will reimburse for the universal vaccination of infants born on and after January 1, 1992, whose immunization was delayed beyond the newborn period because this policy was not yet in effect. However, the immunization schedule must be completed before the infant's second birthday.