Current through Register Vol. 56, No. 18, September 16, 2024
(a) The New Jersey Medicaid/NJ FamilyCare
fee-for-service programs utilize the CMS Healthcare Common Procedure Coding
System (HCPCS). HCPCS follows the American Medical Association's Physicians'
Current Procedural Terminology (CPT) architecture, employing a five-position
code and as many as two 2-position modifiers. Unlike the CPT numeric design,
the CMS assigned codes and modifiers contain alphabetic characters. HCPCS is a
two-level coding system.
1. Level I Codes
(Narratives found in CPT): These codes are adapted from CPT for utilization
primarily by Physicians, Podiatrists, Optometrists, Certified Nurse-Midwives,
Independent Clinics and Independent Laboratories. CPT is a listing of
descriptive terms and numeric identifying codes and modifiers for reporting
medical services and procedures performed by physicians. Copyright restrictions
make it impossible to print excerpts from CPT procedure narrative for Level I
codes. Thus, in order to determine those narratives it is necessary to refer to
CPT, which is incorporated herein by reference, as amended and supplemented.
(The CPT is available from the Order Department of the American Medical
Association, PO Box 109050, Chicago, Illinois 60610.)
2. Level II Codes (Narratives found in
N.J.A.C.
10:62-3.5) : These codes are assigned by CMS
for physician and non-physician services which are not in CPT.
3. Level III Codes (Narratives found in
N.J.A.C.
10:62-3.3 and 3.5): These codes are assigned
by the Division to be used for those services not identified by CPT codes or
CMS-assigned codes. Level III codes identify services unique to New
Jersey.
(b) The HCPCS
procedure codes listed in this subchapter are divided into two sections: HCPCS
procedure codes for professional services are in
N.J.A.C.
10:62-3.2; and HCPCS procedure codes for
vision care appliances are in
N.J.A.C.
10:62-3.5.
(c) The responsibility of the provider when
rendering professional services and requesting reimbursement is listed in
N.J.A.C. 10:62-1, Reimbursement Policies; for optical appliances, N.J.A.C.
10:62-2, Reimbursement Policies.
1. When
filing a claim, the appropriate HCPCS procedure codes must be used in
conjunction with the modifiers when applicable.
2. The use of a HCPCS procedure code will be
interpreted by the New Jersey Medicaid/NJ FamilyCare fee-for-service programs
as evidence that the practitioner personally furnished, at a minimum, the
service which the code represents.
3. For reimbursement purposes, when reference
is made to any of the following services it is understood that they were
performed by the practitioner submitting the claim:
i. Office, hospital, nursing home, or
residential health care facility visits; and
ii. Any and all parts of a history or eye
examination.
4. Date(s)
of service(s) shall be indicated on the claim form and in the practitioner's
own record for each service billed.
5. When submitting a claim, the practitioner
shall always use the practitioner's usual and customary fee. The New Jersey
Medicaid/NJ FamilyCare fee-for-service dollar value designated for the HCPCS
procedure codes represents the New Jersey Medicaid/NJ FamilyCare
fee-for-service programs' maximum payment for the given procedure.
i. All references to time parameters shall
mean the practitioner's time in reference to the service rendered unless it is
otherwise indicated.
(d) Regarding specific elements of HCPCS
procedure codes which require attention of providers, the lists of HCPCS
procedure codes for vision care services are arranged in tabular form with
specific information for a code identified under columns with titles such as:
"IND," "HCPCS CODE," "MOD," "DESCRIPTION," AND "MAXIMUM FEE ALLOWANCE." The
information identified under each column is summarized below:
Click
here to view image.
(e) Regarding alphabetic and numeric symbols
under "IND" and "MOD", these symbols when listed under the "IND" and "MOD"
columns are elements of the HCPCS coding system used as qualifiers or
indicators (as in the "IND" column) and as modifiers (as in the "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.
1. These symbols and letters must not be
ignored because, in certain instances, requirements are created in addition to
the narrative that accompanies the HCPCS procedure code as written in CPT. The
provider must be careful to enter the additional requirements, and not just the
HCPCS procedure code narrative. These requirements must be fulfilled in order
to receive reimbursement.
2. If
there is no identifying symbol listed, the HCPCS procedure code narrative
prevails.
(f) For
surgical codes relevant to Ophthalmologists see Physicians Services Chapter
(N.J.A.C. 10:54-4, CMS Healthcare Common Procedure Coding System).
