New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 58 - NURSE MIDWIFERY SERVICES
Subchapter 1 - GENERAL PROVISIONS
Section 10:58-1.7 - Basis of reimbursement

Universal Citation: NJ Admin Code 10:58-1.7

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Reimbursement for certified nurse midwifery services shall be based upon the provider's usual and customary charge or the allowance determined by the Commissioner of the Department of Human Services and contained in N.J.A.C. 10:58-3, whichever is less.

(b) A certified nurse midwife who is approved as a provider of services by the New Jersey Medicaid or the NJ FamilyCare programs, and who practices independently and not as part of a physician group or other organized medical care entity, may be directly reimbursed by the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service programs, in accordance with the provisions of this chapter.

(c) The basis for reimbursement of services provided in a birth center is as follows:

1. The birth center shall receive a facility fee of $ 1,300, exclusive of laboratory, drugs, and professional fees, for beneficiaries attended on-site during labor and delivery.

2. A birth center shall receive a facility fee of $ 500.00, exclusive of laboratory, drugs, and professional fees, for beneficiaries who are admitted to the birth center in labor but subsequently transferred to a hospital.

3. The HCPCS codes for billing for birth center facility services are described in 10:58-3.5(g).

4. A birth center shall be reimbursed for professional CNM services provided by a CNM employed by the birth center in accordance with 10:58-1.6(a). The birth center shall not be reimbursed for professional CNM services provided by a CNM who is an independent provider.

5. A physician who provides professional services in a birth center shall bill for his or her services in accordance with 10:54-4.33 in order to receive reimbursement for professional services.

6. A birth center billing for laboratory services shall meet all requirements found in 10:58-2.9 through 2.13.

7. A birth center billing for medications shall meet all requirements found in 10:58-2.17.

8. A birth center may bill for certain injections relative to maternity care or provided to the newborn at the time of delivery, in accordance with 10:58-3.5(c).

(d) A certified nurse midwife who is salaried and whose services are reimbursed as part of the hospital's cost shall not bill fee-for-service to the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service program. A certified nurse midwife who is practicing in a hospital outpatient department and whose reimbursement is not part of the hospital's cost may bill fee-for-service to the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service program, independent of the hospital charges, if the arrangement with the hospital permits it.

(e) When a certified nurse midwife is employed by a physician, nurse midwifery services shall be identified as separate and distinct from physician services by utilization of procedure codes with the "WM" modifier, as designated under the CMS Healthcare Common Procedure Coding System (HCPCS) in N.J.A.C. 10:58-3.

(f) When a certified nurse midwife is employed by a clinic, nurse midwifery services shall be identified by utilization of the procedure code with the "WM" modifier as designated under the Healthcare Common Procedure Coding System (HCPCS) in N.J.A.C. 10:66.

(g) For the requirements for HealthStart Maternity providers, see 10:58-2.5, 3.5 and 3.6(h).

(h) Reimbursement shall not be made for, and clients shall not be asked to pay for, broken appointments.

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