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. 18, September 16, 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:
(c) Specific elements of HCPCS codes require the attention of providers. The lists of HCPCS code numbers for podiatric services are arranged in tabular form with specific information for a code given under columns with titles such as: "IND," "HCPCS CODE," "MOD," "DESCRIPTION," "FOLLOW-UP DAYS," "MAXIMUM FEE ALLOWANCE" and "ANES BASIC UNITS." The information given under each column is summarized below:
These symbols, when listed under the "IND" and "MOD" columns, are elements of the HCPCS coding system used as qualifiers or indicators ("IND" column) and as modified ("MOD" column). They assist the provider in determining the appropriate procedure codes to be used, the area to be covered, the minimum requirements needed, and any additional parameters required for reimbursement purposes.
IND = | lists alphabetic symbols used to refer the provider to |
information concerning the New Jersey Medicaid or NJ | |
FamilyCare programs' qualifications and requirements when | |
a procedure or service code is used. An explanation of the | |
indicators and qualifiers used in this column is located | |
below and in paragraph 1, "Alphabetic and numeric symbols," | |
as follows: | |
A = | "A" preceding any procedure code indicates that these tests |
can be and are frequently done as groups and combinations | |
(profiles) on automated equipment. | |
D = | "D" preceding any procedure code indicates that the procedure |
code is excluded from the requirement that office visit codes | |
not be reimbursed in addition to procedure codes for surgical | |
procedures performed in the office. | |
E = | "E" preceding any procedure code indicates that these |
procedures are excluded from multiple surgery pricing and, | |
as such, should be reimbursed at 100 percent of the | |
Medicaid/NJ FamilyCare maximum fee allowance, even if the | |
procedure is done on the same patient by the same surgeon at | |
the same operative session. | |
L = | "L" preceding any procedure code indicates that the complete |
narrative for the code is located in 10:57-3.3. | |
N = | "N" preceding any procedure code means that qualifiers are |
applicable to that code. (See 10:57-3.4.) | |
HCPCS | |
CODE = | HCPCS procedure code numbers. |
MOD = | Alphabetic and numeric symbols: Under certain circumstances, |
services and procedures may be modified by the addition of | |
alphabetic and/or numeric characters at the end of the code. | |
The New Jersey Medicaid and NJ FamilyCare programs' modifier | |
codes for podiatry services are: | |
22 = | Unusual Services: When the service(s) provided is greater than |
that usually required for the listed procedure, it may be | |
identified by adding modifier '22' to the usual procedure | |
number. | |
26 = | Professional Component: Certain procedures are a combination |
of a physician and a technical component. When the physician | |
component is reported separately, the service may be | |
identified by adding the modifier '26' to the usual procedure | |
number. If a professional component type service is keyed | |
without the '26' modifier and a manual pricing edit is | |
received, resolve the edit by adding the '26' modifier. | |
50 = | Bilateral Procedure: Unless otherwise identified in the |
listing, bilateral procedures requiring separate incisions | |
that are performed at the same operative session, should be | |
identified by the appropriate five-digit code describing the | |
first procedure. The second (bilateral) procedure is | |
identified by adding modifier '50' to the procedure number. | |
51 = | Multiple Procedures: When multiple procedures are performed |
at the same operative session, the major procedure may be | |
reported as listed. The secondary, additional or lesser | |
procedure(s) may be identified by adding the modifier '51' | |
to the secondary procedure number(s). | |
52 = | Reduced Services: Under certain circumstances, a service or |
procedure is partially reduced or eliminated at the | |
podiatrist's election. Under these circumstances the service | |
provided can be identified by its usual procedure number and | |
the addition of the modifier '52' signifying that the service | |
is reduced. This provides a means of reporting reduced | |
services without disturbing the identification of the basic | |
service. | |
62 = | Two Surgeons: Under certain circumstances, the skill of two |
surgeons (usually with different skills) may be required in | |
the management of a specific procedure. Under such | |
circumstances the separate services may be identified by | |
adding the modifier '62' to the procedure number used by | |
each surgeon for reporting his or her services. | |
66 = | Surgical Team: Under some circumstances, highly complex |
procedures (requiring the concomitant services of several | |
physicians or podiatrists, often of different specialties, | |
plus other highly skilled, specially trained personnel and | |
various types of complex equipment) are carried out under | |
the "surgical team" concept. Such circumstances may be | |
identified by each participating physician or podiatrist | |
with the addition of the modifier '66' to the basic procedure | |
number used for reporting services. | |
76 = | Repeat Procedure By Same Podiatrist: The podiatrist may need |
to indicate that a procedure or service was repeated | |
subsequent to the original service. This circumstance may be | |
reported by adding the modifier '76' to the repeated service. | |
77 = | Repeat Procedure By Another Podiatrist: The podiatrist may |
need to indicate that a basic procedure performed by another | |
podiatrist had to be repeated. This situation may be reported | |
by adding modifier '77' to be repeated service. | |
80 = | Assistant Surgeon: Surgical assistant services are identified |
by adding this modifier '80' to the usual procedure number(s). | |
81 = | Minimum Assistant Surgeon. |
82 = | Assistant Surgeon (when a qualified resident surgeon is not |
available). | |
TC = | When applicable, a charge may be made for the technical |
component alone. Under those circumstances the technical | |
component is identified by adding the modifier 'TC' to the | |
usual procedure code. | |
DESCRIPTION = | Code narrative: |
Narratives for Level I codes are found in CPT. Narratives | |
for Level II Codes are found at 10:57-3.3. | |
FOLLOW-UP | Number of days for follow-up care which are considered as |
DAYS = | included as part of the procedure code for which no additional |
reimbursement is available. | |
MAXIMUM FEE | New Jersey Medicaid/NJ FamilyCare program's maximum |
ALLOWANCE = | reimbursement allowance. If the symbols "B.R." (By Report) |
are listed instead of a dollar amount, it means that | |
additional information will be required in order to evaluate | |
and price the service. Attach a copy of any additional | |
information to the claim form. | |
ANES BASIC | B.U.V. (Basic Unit Value) + A.T. (Anesthesia Time Per Unit) |
UNITS = | x $9.30 (Specialist) or $8.10 (non-specialist) equals |
reimbursement. Anesthesia Time per Unit is 15 minutes = | |
1 unit. |
(d) Listed in this subsection are general policies of the New Jersey Medicaid/NJ FamilyCare program that pertain to HCPCS. Specific information concerning the responsibilities of a podiatrist when rendering Medicaid/NJ FamilyCare fee-for-service covered services and requesting reimbursement are located at N.J.A.C. 10:57-1.8, Recordkeeping, and 1.6, Basis of reimbursement.