New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 58 - NURSE MIDWIFERY SERVICES
Subchapter 3 - CENTERS FOR MEDICARE & MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS
Section 10:58-3.6 - HCPCS codes qualifiers for certified nurse midwifery services
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Surgical services: Norplant System (NPS)
11975 WM | QUALIFIER: Reimbursed for the insertion and reinsertion of the |
Norplant System (six Levonorgestrel Implants) and the | |
post-insertion visit when provided in a hospital setting, when | |
the CNM bills for the service. When using this procedure code, | |
the CNM will not be reimbursed for the cost of the kit. The | |
supplier of the kit to the CNM will be either reimbursed by | |
the hospital or be reimbursed directly for the cost of the | |
kit. | |
11975 WM 22 | QUALIFIER: The maximum fee allowance includes the cost of the |
kit supplied to the CNM, the insertion of the Norplant System | |
(six Levonorgestrel Implants), and the post-insertion visit. | |
NOTE: The "22" modifier indicates the inclusion of the cost of | |
the kit. | |
11976 WM | QUALIFIER: The maximum fee allowance is reimbursed for the |
removal of the Norplant System (six Levonorgestrel Implants) | |
and the post-removal visit. | |
11977 WM | QUALIFIER: The maximum fee allowance is reimbursed for the |
removal and reinsertion of the Norplant System (six | |
Levonorgestrel Implants) and the post-removal/reinsertion | |
visit. | |
11977 WM 22 | QUALIFIER: The maximum fee allowance is reimbursed for the |
removal and reinsertion of the "Norplant System" (six | |
Levonorgestrel Implants) and for the post-removal/reinsertion | |
visit. NOTE: Modifier "22" indicates that the billing includes | |
the cost of the NPS kit. |
(b) Laboratory services:
36415 | QUALIFIER: Once per visit, per patient. Not applicable if |
laboratory study, in any part, is performed by the office | |
staff of the CNM or by CNM herself. When the clinical | |
laboratory test is performed on site, the venipuncture is not | |
reimbursable as a separate procedure; its cost is included | |
within the reimbursement for the laboratory procedure. |
(c) Immunization:
W9098 | QUALIFIER: This code applies only to high risk beneficiaries |
who are 19 years of age. | |
W9335 | QUALIFIER: This code applies only to high risk beneficiaries |
who are over 18 years of age. | |
90741 | QUALIFIER: Prior authorization form the Medical Consultant at |
the Medicaid District Office is required. | |
90742 | QUALIFIER: Prior authorization from the Medical Consultant at |
the Medicaid District Office is required. |
(d) Infusion therapy (excluding allergy, immunization and chemotherapy):
90772 SB | QUALIFIER: Reimbursement is contingent upon the required |
medical necessity, and written chart documentation, including | |
time and the indication of the CNM's presence with the patient | |
to the exclusion of her other duties. | |
90774 SB | QUALIFIER: Reimbursement is contingent upon the required |
medical necessity, and written chart documentation, including | |
time and the indication of the CNM's presence with the patient | |
to the exclusion of her other duties. | |
90775 SB | QUALIFIER: Reimbursement is contingent upon the required |
medical necessity, and written chart documentation, including | |
time and the indication of the CNM's presence with the patient | |
to the exclusion of her other duties. | |
90779 SB | QUALIFIER: Reimbursement is contingent upon the required |
medical necessity, and written chart documentation, including | |
time and the indication of the CNM's presence with the patient | |
to the exclusion of her other duties. |
(e) Evaluation and management services:
For policy related to qualifiers for the following codes, see 10:58-2.3. (99201WM, 99202WM, 99203WM, 99204WM, 99211WM, 99212WM. 99213WM, 99214WM, 99215WM, 99221WM, 99231WM, 99232WM, 99351WM, 99352WM, 99384WM, 99385WM, 99386WM, 99387WM, 99394WM, 99395WM, 99396WM, 99397WM.)
QUALIFIER: An Initial Office Visit is limited to a single visit. Future use of this category of codes will be denied when the beneficiary is seen by the same practitioner, group of practitioners, or member of the same shared health care facility.
New Patient | Established Patient |
99384 WM | 99394 WM |
99385 WM | 99395 WM |
99386 WM | 99396 WM |
99387 WM | 99397 WM |
W9820 WM | Early and Periodic Screening, Diagnosis and Treatment (EPSDT) |
through age 20. | |
QUALIFIER: Procedure code W9820 shall be used only once for | |
the same patient during any 12-month period by the same | |
practitioner(s) sharing a common record. | |
QUALIFIER: Reimbursement for code W9820 is contingent upon | |
the submission of a completed "Report and Claim for | |
EPSDT/HealthStart Screening and Related Procedures" (MC-19) | |
form within 30 days of the date of service. |
(f) Obstetrical services:
59400 WM | Total obstetrical care including antepartum care consisting of |
initial antepartum visit and seven subsequent antepartum | |
visits, vaginal delivery (with or without episiotomy, and/or | |
forceps) and postpartum care when performed by a certified | |
nurse midwife. If fewer than eight antepartum visits and one | |
postpartum visit are provided, this HCPCS code must not be | |
used for billing purposes. In this situation, each visit must | |
be billed individually with the appropriate procedure code | |
designation. Include delivery date on the HCFA 1500 claim form | |
in Item 24A. |
ADDITIONAL VISITS ABOVE SEVEN ANTEPARTUM VISITS--99211WM, 99212WM, 99213WM, 99215WM, 99351WM, 99352WM
NOTE: If medical necessity dictates, corroborated by the record, then additional visits (home or office) above seven antepartum visits may be reimbursed. The claim form should clearly indicate the medical necessity and the date for each office or home visit listed.
59409 WM | VAGINAL DELIVERY ONLY, WITH OR WITHOUT EPISIOTOMY AND/OR |
FORCEPS BY A CERTIFIED NURSE MIDWIFE | |
59410 WM | REGULAR DELIVERY AND POSTPARTUM VISIT BY A CERTIFIED NURSE |
MIDWIFE | |
This applies to a vaginal delivery (full term or premature, | |
with or without episiotomy, and/or forceps) and includes one | |
out-of-hospital visit between the 15th and 60th postpartum day | |
following delivery. Include delivery date on the claim form in | |
Item 24A on the HCFA 1500 claim form. | |
59430 WM | Postpartum visit by other than the delivering physician or |
delivering certified nurse midwife. One out-of-hospital visit | |
between the 15th and 60th postpartum day. | |
W9855 WM | Initial Antepartum visit by a Certified Nurse Midwife. |
(Separate procedure.) | |
W9856 WM | Subsequent Antepartum Visit by a Certified Nurse Midwife. |
(Separate procedure.) Indicate the specific dates of service | |
on the HCFA 1500 claim form on Item 24. |
(g) HealthStart Maternity Medical Care Services codes are as follows:
W9025 WM | HealthStart INITIAL ANTEPARTUM MATERNITY MEDICAL CARE VISIT |
BY CERTIFIED NURSE MIDWIFE | |
HealthStart INITIAL ANTEPARTUM MATERNITY MEDICAL CARE VISIT | |
BY CERTIFIED NURSE MIDWIFE includes: | |
1. History, including system review | |
2. Complete physical examination | |
3. Risk assessment | |
4. Initial care plan | |
5. Patient counseling and treatment | |
6. Routine and special laboratory tests on site, or by | |
referral, as appropriate | |
7. Referral for other medical consultations, as appropriate | |
(including dental) | |
8. Coordination with the HealthStart Health Support Services | |
provider, as applicable. | |
W9026 WM | HealthStart SUBSEQUENT ANTEPARTUM MATERNITY MEDICAL CARE |
VISIT BY CERTIFIED NURSE MIDWIFE | |
HealthStart SUBSEQUENT ANTEPARTUM MATERNITY MEDICAL CARE | |
VISIT BY CERTIFIED NURSE MIDWIFE includes: | |
1. Interim history | |
2. Physical examination | |
3. Risk assessment | |
4. Review of plan of care | |
5. Patient counseling and treatment | |
6. Laboratory services on site or by referral, as appropriate | |
7. Referrals for other medical consultations, as appropriate | |
8. Coordination with HealthStart case coordinator. | |
NOTE: This code may be billed only for the second through 15th | |
antepartum visit. | |
NOTE: If medical necessity dictates, corroborated by the | |
record, additional visits above the 15th visit may be | |
reimbursed under procedure code for routine or follow-up | |
visit--midwife, that is, OFFICE: 99211WM, 99212WM, 99213WM, | |
99214WM, 99215WM, or HOME: 99351WM, 99352WM. The date and | |
place of service shall be included on each claim detail line | |
on the HCFA 1500 claim form. The claim form should clearly | |
indicate the reason for the medical necessity and date for | |
each additional visit. | |
W9027 | HealthStart REGULAR DELIVERY BY CERTIFIED NURSE MIDWIFE |
HealthStart REGULAR DELIVERY BY CERTIFIED NURSE MIDWIFE | |
includes: | |
1. Admission history | |
2. Complete physical examination | |
3. Vaginal delivery with or without episiotomy and/or forceps | |
4. Inpatient postpartum care | |
5. Referral to postpartum follow-up care provider including: | |
i. Mother's hospital discharge summary and | |
ii. Infant's discharge summary, as appropriate | |
NOTE: Obstetrical delivery applies to a full term or premature | |
vaginal delivery and includes care in the home, birthing | |
center or in the hospital (inpatient setting). Include the | |
delivery date on the HCFA 1500 claim form in Item 24A. | |
W9028 WM | HealthStart POSTPARTUM CARE VISIT BY CERTIFIED NURSE MIDWIFE |
HealthStart POSTPARTUM CARE VISIT BY CERTIFIED NURSE MIDWIFE | |
includes: | |
1. Outpatient postpartum care by the 60th day after the | |
vaginal or caesarean section delivery | |
i. Review of prenatal, labor and delivery course; | |
ii. Interim history, including information on feeding and | |
care of the newborn; | |
iii. Physical examination; | |
iv. Referral for laboratory services, as appropriate; | |
v. Referral for ongoing medical care when appropriate; | |
vi. Patient counseling and treatment; | |
NOTE: The postpartum visit shall be made by the 60th | |
postpartum day. Include the delivery date on the HCFA 1500 | |
claim form in Item 24A. | |
W9029 WM | HealthStart REGULAR DELIVERY AND POSTPARTUM BY CERTIFIED NURSE |
MIDWIFE | |
HealthStart REGULAR DELIVERY AND POSTPARTUM BY CERTIFIED NURSE | |
MIDWIFE includes: | |
1. Admission history | |
2. Complete physical examination | |
3. Vaginal delivery with or without episiotomy and/or forceps | |
4. Inpatient postpartum care | |
5. Referral to postpartum follow-up care provider including: | |
i. Mother's hospital discharge summary; | |
ii. Infant's discharge summary, as appropriate. | |
6. Outpatient postpartum care by the 60th day after the | |
delivery | |
i. Review of prenatal, labor and delivery course; | |
ii. Interim history, including information on feeding and | |
care of the newborn; | |
iii. Physical examination; | |
iv. Referral for laboratory services, as appropriate; | |
v. Referral for ongoing medical care when appropriate; | |
vi. Patient counseling and treatment. | |
NOTE: This code applies to a full term or premature vaginal | |
delivery and includes care in the home, birthing center or in | |
the hospital (inpatient setting). Include delivery date on the | |
HCFA 1500 claim form in Item 24A. | |
W9030 WM | HealthStart TOTAL OBSTETRICAL CARE BY CERTIFIED NURSE MIDWIFE |
Total obstetrical care consists of: | |
1. INITIAL ANTEPARTUM VISIT AND FOURTEEN SUBSEQUENT ANTEPARTUM | |
VISITS BY THE CERTIFIED NURSE MIDWIFE. Specific dates are to | |
be listed on the claim form. | |
NOTE: Reimbursement will be denied if the services delivered | |
do not meet the criteria for the visits. The elements of the | |
visits shall include the following: | |
i. History (initial or review), including system review; | |
ii. Complete physical examination; | |
iii. Risk assessment; | |
iv. Initial and ongoing care plan; | |
v. Patient counseling and treatment; | |
vi. Routine and special laboratory tests on site, or by | |
referral, as appropriate; | |
vii. Referral for other medical consultations, as | |
appropriate (including dental); | |
viii. Coordination with the HealthStart Health Support | |
Services provider, as applicable. | |
2. REGULAR VAGINAL DELIVERY BY CERTIFIED NURSE MIDWIFE: | |
The elements of the care shall include the following: | |
i. Admission history; | |
ii. Complete physical examination; | |
iii. Vaginal delivery with or without episiotomy and/or | |
forceps; | |
iv. Inpatient postpartum care. | |
NOTE: Include the delivery date on the HCFA 1500 claim form | |
in Item 24. | |
3. POSTPARTUM CARE VISIT BY CERTIFIED NURSE MIDWIFE: | |
Outpatient postpartum care by the 60th day after the vaginal | |
delivery (full term of premature): | |
i. Review of prenatal, labor and delivery course; | |
Interim history, including information on feeding and care of | |
the newborn; | |
Physical examination; | |
iv. Referral for laboratory services, as appropriate; | |
v. Referral for ongoing medical care when appropriate; | |
vi. Patient counseling and treatment. |