Current through Register Vol. 56, No. 18, September 16, 2024
(a) For purposes of reimbursement, a podiatrist and/or physician; podiatrist and/or physicians' group; shared health care facility; or providers sharing a common record are considered a single provider.
(b) When reference is made in the CPT manual to 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; the intent of Medicaid/NJ FamilyCare is to consider this service as the initial visit. When the setting for this initial visit is an office or residential health care facility, for reimbursement purposes it is limited to a single visit. Future use of this category of codes will be denied when the recipient is seen by the same physician, group of physicians, or involves a shared health care facility which is a group of physicians sharing a common record. Reimbursement for an initial office visit also precludes subsequent reimbursement for an initial residential health care facility visit and vice versa.
1. Reimbursement for an initial office visit or initial residential health care facility visit will be disallowed, if a preventive medicine service, EPSDT examination or office consultation were billed within a 12-month period by a podiatrist, podiatric group, shared health care facility, or practitioner sharing a common record.
2. If the setting is a nursing facility or hospital, the initial visit concept will still apply for reimbursement purposes despite CPT reference to the term initial hospital care or comprehensive nursing facility assessments. Subsequent readmissions to the same facility may be reimbursed as initial visits, if the readmission occurs more than 30 days from a previous discharge from the same facility by the same provider. In instances when the readmission occurs within 30 or less days from a previous discharge, the provider shall bill the relevant HCPCS procedure codes specified in the qualifier under the headings Subsequent hospital care or Subsequent nursing facility care.
3. Initial hospital visit during a single admission will be disallowed to the same physician, group, shared health care facility, or practitioners sharing a common record who submit a claim for a consultation and transfer the patient to their service. It is also to be understood that in order to receive reimbursement for an initial visit, one of the minimum documentation requirements must be met.
i. HCPCS 99201 and 99202 are exceptions to the above requirements outlined in the qualifier for the initial visit. For HCPCS 99201 and 99202, the provider shall follow the qualifier applied to routine visit or follow-up care visit, for reimbursement purposes.
ii. When reference is made, in the CPT, to 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; the intent of Medicaid/NJ FamilyCare is to consider this service as the Routine Visit or Follow-Up Care visit. The setting could be office, hospital, nursing facility or residential health care facility. In order to document the record for reimbursement purposes, a progress note for the noted visits should include the minimum documentation specified in 10:57-1.8.
iii. House call procedure codes refer to a podiatrist visit limited to the provision of podiatric care to an individual who would be too ill to go to a podiatrist's office and/or is "home bound" due to his/her physical condition. When billing for a second or subsequent patient treated during the same visit, the visit should be billed as a home visit.
