Current through Register Vol. 56, No. 18, September 16, 2024
(a) The evaluation and management codes can indicate services performed in a clinical practitioner's office, in a patient's home, in a boarding home, in nursing facilities and residential health care facilities, in clinics, in Federally qualified health centers (FQHCs), and in hospitals.
(b) 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 was billed within a 12-month period by the same clinical practitioner, group of clinical practitioners, or shared health care facility sharing a common record.
(c) Provisions for initial visits, evaluation and management are:
1. For office visits and for other care apart from inpatient hospital, providers are permitted to bill for an initial visit only once for a specific patient, subject to the following exceptions.
i. When a shared health care facility, a group of physicians and/or other practitioners including, but not limited to, APNs, share a common record, the Division will reimburse only one initial visit to that provider group.
ii. Further encounters with that patient will be billed and reimbursed by means of "established patient" codes. See 10:58A-4.1 through 4.5.
iii. Reimbursement for an initial office visit also precludes subsequent reimbursement to the same provider for an initial residential health care facility visit and vice versa.
2. If the setting is a nursing facility, the initial visit concept will still apply when considered for reimbursement purposes; however, subsequent readmissions to the same facility may be designated as initial visits, as long as a time interval of 30 days or more has elapsed between admissions.
3. In the inpatient hospital setting, the initial visit concept still applies for reimbursement purposes, except that subsequent readmissions to the same facility may be designated as initial visits, as long as a time interval of 30 days or more has elapsed between admissions.
4. An initial hospital visit will be disallowed to the same clinical practitioner, group of clinical practitioners, shared health care facility, or clinical practitioners sharing a common record who submit a claim for a consultation and transfer the patient to their service.
5. In order to use the HCPCS procedure code to bill for an initial visit, the APN shall provide the minimal documentation in the record regardless of the setting where the examination was performed. See 10:58A-1.4(c).
(d) Provisions for office or other outpatient services-established patient, or subsequent hospital care: evaluation and management services:
1. This service is considered to be the routine office visit or follow-up care visit, and the visit will conform to the CPT description of provider involvement and time. The setting could be office, hospital, nursing facility or residential health care facility. The documentation requirements for these visits can be found at 10:58A-1.4.
(e) In the absence of patient complaints, the procedure codes identified as preventive medicine services are applied, for adults and for children.
1. Preventive medicine services codes (new patient) are comparable, in respect to reimbursement level, to an initial visit and, therefore, may only be billed once per patient. Future use of these codes will be denied when the beneficiary is seen by the same clinical practitioner, group of clinical practitioners, or involves a shared health care facility sharing a common record.
(f) The following apply to preventive medicine services, the annual health maintenance examination, for new or established patients under the age of 21:
1. These codes are not allowable for payment when used following an EPSDT or HealthStart pediatric examination performed within the preceding 12 months for a child older than two years of age.
2. For well-child care provided to children under the age of two, the provider is urged to use age-appropriate EPSDT or pediatric HealthStart codes.
3. Preventive medicine codes may be used up to six times (at ages one, two, four, six, nine and 12 months) during the patient's first year of life and up to three times (at ages 15, 18 and 24 months) during the patient's second year of life, in accordance with the periodicity schedule of preventive visits recommended by the American Academy of Pediatrics. These codes should not be used for children under two years of age participating in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) or Pediatric HealthStart program.
(g) Concerning the consultation procedures, in reference to APNs, a consultation is eligible for reimbursement only when performed by a physician specialist recognized as such by the Division, when the request has been made by or through the patient's attending physician or APN, and the need for such a request would be consistent with good medical practice. APNs will not be reimbursed for consultation procedures, but mention of these procedures is included for those instances when the APN needs to refer patient(s) for consultation, to a specialist other than the collaborating physician.
(h) The home services recognized as "house calls" refer to a clinical practitioner visit limited to the provision of medical care to an individual who would be too ill to go to a clinical practitioner's office and/or is "home bound" due to his or her physical condition. These codes do not apply to the residential health care facility or nursing facility setting.
1. For purposes of Medicaid/NJ FamilyCare fee-for-service reimbursement, "home visits" apply when the provider visits Medicaid/NJ FamilyCare fee-for-service beneficiaries who do not qualify as "home bound."
(i) The following concern emergency department and inpatient hospital services:
1. When a clinical practitioner sees a patient in the emergency room instead of the provider's office, the clinical practitioner shall use the same codes for the visit that would have been used if seen in the provider's office. Records of that visit should become part of the notes in the provider's office chart.
2. When patients are seen by hospital-based emergency room APNs who are eligible to bill the Medicaid or the NJ FamilyCare fee-for-service program, the appropriate HCPCS code is used. These "visit" codes are listed at 10:58A-4.2.
3. Critical care/prolonged services will be covered when the patient's situation requires constant clinical practitioner attendance given by the clinical practitioner to the exclusion of other patients and duties, and, therefore, represents what is beyond the usual service.
i. Critical care/prolonged success shall be verified by the applicable records as defined by the setting. The records shall show in the clinical practitioner's authorized documentation the time of onset and time of completion of the service. All settings are applicable such as office, hospital, home, residential health care facility and nursing facility.
ii. The reimbursement for the "critical care" or prolonged services utilizes the time parameter, and is all-inclusive, meaning that it will be the only payment for care provided by the clinical practitioner to the patient at that time. The specific procedures performed during that patient encounter will not be reimbursed in addition to the "critical care/prolonged services" payment.
4. For reimbursement purposes, routine hospital "newborn care for a well baby" requires, as a minimum, routine newborn care by a clinical practitioner other than the clinical practitioner(s) rendering maternity service.
i. "Newborn care for a well baby" includes complete initial and complete discharge physical examination, and conference(s) with the parent(s). These examinations shall be documented in the newborn's medical record.
ii. This code applies to healthy newborns and the fee for this service is all-inclusive. Consequently, the provider may not bill multiple units or bill for visits made on the subsequent day or the discharge day for a healthy newborn.
iii. For sick babies, use the appropriate hospital care code, as indicated at 10:58A-4.2.
