New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 66 - INDEPENDENT CLINIC SERVICES
Subchapter 6 - CENTERS FOR MEDICARE & MEDICAID SERVICES HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
Section 10:66-6.1 - Introduction
Universal Citation: NJ Admin Code 10:66-6.1
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The New Jersey Medicaid and NJ FamilyCare fee-for-service programs utilize the Centers for Medicare & Medicaid Services (CMS)'s Healthcare Common Procedure Code System (HCPCS) for 2009, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191, and incorporated herein by reference, as amended and supplemented, and as published by PMIC, 4727 Wilshire Blvd., Suite 302, Los Angeles, CA 90010. Revisions to the Healthcare Common Procedure Coding System made by CMS, including, but not limited to, 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, N.J.S.A. 52:14B-1 et seq. HCPCS follows the American Medical Association's Physicians' Current Procedure 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. HCPCS is a two-level coding system.
1. Level 1 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 narratives 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. 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
www.ama-assn.org. An updated copy
of the HCPCS (Level II) codes may be obtained by accessing the HCPCS website at
www.cms.hhs.gov/medicare/hcpcs
or by contacting PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA
90010.
2. Level II codes: These
codes are assigned by CMS for physician and non-physician services that are not
in CPT. Narratives for Level II codes can be found at
N.J.A.C.
10:66-6.3.
(b) Regarding specific elements of HCPCS codes which require the attention of providers, the lists of HCPCS code numbers for independent clinic 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" and "MAXIMUM FEE ALLOWANCE." The information given under each column is summarized below:
| Column Title | Description |
|---|---|
| IND | (Indicator-Qualifier) lists alphabetic symbols used |
| to refer the provider to information concerning the New | |
| Jersey Medicaid and NJ FamilyCare fee-for-service | |
| program's qualifications and requirements when a | |
| procedure or service code is used. An explanation of | |
| the indicators and qualifiers used in this column are | |
| located below and in paragraph 1, "Alphabetic and | |
| numeric symbols," as follows: | |
| Indicator | Description |
| "L" | "L" preceding any procedure code indicates that the |
| complete narrative for the code is located at N.J.A.C. | |
| 10:66-6.3. | |
| "N" | "N" preceding any procedure code means that |
| qualifiers are applicable to that code. These | |
| qualifiers are listed by procedure code number at | |
| 10:66-6.4. | |
| HCPCS CODE | HCPCS procedure code numbers. |
| MOD | Alphabetic and numeric symbols: Services and |
| procedures may be modified under certain circumstances. | |
| When applicable, the modifying circumstances are | |
| identified by the addition of alphabetic and/or numeric | |
| characters at the end of the code. The New Jersey | |
| Medicaid and NJ FamilyCare fee-for-service program's | |
| recognized modifier codes for independent clinic | |
| services are as follows: | |
| Modifer Code | Description |
| 22 | Unusual services: When the service provided is |
| greater than that usually required for the listed | |
| procedure, it may be identified by adding modifier "22" | |
| to the usual procedure number. | |
| 50 | Bilateral procedures: Unless otherwise identified in |
| the listings, bilateral procedures requiring a separate | |
| incision 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. | |
| 52 | Reduced services: Under certain circumstances a |
| service or procedure is partially reduced or eliminated | |
| at the physician'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. | |
| AA | Anesthesia services performed personally by an |
| anesthesiologist. | |
| EP | Services provided as part of Medicaid Early Periodic |
| Screening, Diagnostic and Treatment (EPSDT) Services | |
| Program; add the modifier "EP" to only those procedure | |
| codes so indicated at 10:66-6.2. | |
| N | Preceding any code means that qualifiers are |
| applicable to that code. | |
| UC | Independent clinic: To identify certain mental |
| health services provided by independent clinic | |
| providers, add the modifier "UC" to only those | |
| procedure codes so indicated at 10:66-6.2(f) | |
| and (o). | |
| FP | Family planning: To identify procedures performed |
| for the sole purpose of family planning, add the | |
| modifier "FP" to only those procedure codes so | |
| indicated at 10:66-6.2. | |
| HD | OB/GYN encounter in FQHC |
| HE | Mental health program services |
| SA | Advanced Practice Nurse: to identify procedures |
| performed by an Advanced Practice Nurse; add the | |
| modifier "SA" to only those procedure codes so | |
| indicated at 10:66-6.2. | |
| SB | Certified nurse-midwife: To identify procedures |
| performed by a certified nurse-midwife, add the | |
| modifier "SB" to only those procedure codes so | |
| indicated at 10:66-6.2. | |
| SM | Second surgical opinion. |
| SN | Third surgical opinion. |
| UA | Only applies to billing by an ambulatory surgical |
| center: To identify the trimester (1st trimester) of an | |
| abortion procedure, add the modifier "UA" to the | |
| procedure code. | |
| UB | Only applies to billing by an ambulatory surgical |
| center: To identify the trimester (2nd trimester) of an | |
| abortion procedure, add the modifier "UB" to the | |
| UC | Independent clinic: To identify certain mental health and related transportation services provided by independent clinic providers, add the modifier 'UC' to only those procedure codes so indicated at N.J.A.C. 10:66-6.2(f) and (l). |
| procedure code. | |
| UD | Procedure performed in relation to abortion |
| services. | |
| DESCRIPTION | Code narrative: Narratives for Level I codes are |
| found in CPT. Narratives for Level II and III codes are | |
| found at 10:66-6.3. | |
| FOLLOW-UP DAYS | Number of days for follow-up care. |
| MAXIMUM FEE | New Jersey Medicaid and NJ FamilyCare |
| ALLOWANCE | fee-for-service programs maximum reimbursement |
| allowance for specialist and non-specialist: 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 properly evaluate the | |
| service. Attach a copy of the report to the claim form. |
(c) Listed below are both general and specific policies of the New Jersey Medicaid and NJ FamilyCare fee-for-service programs that pertain to HCPCS. Specific information concerning the responsibilities of an independent clinic provider when rendering Medicaid-covered and NJ FamilyCare fee-for-service-covered services and requesting reimbursement are located at N.J.A.C. 10:66-1 through 5, and 10:66 Appendix.
1. General
requirements are as follows:
i. When filing a
claim, the appropriate HCPCS procedure codes must be used in conjunction with
modifiers when applicable.
ii. The
use of a procedure code will be interpreted by the New Jersey Medicaid and NJ
FamilyCare fee-for-service programs as evidence that the provider personally
furnished, as a minimum, the services for which it stands.
iii. When billing, the provider must enter
onto the claim form a CPT/HCPCS procedure code as listed in CPT or in this
subchapter. If an appropriate code is not listed, place an "N/A" (not
applicable) in the procedure code column and submit a narrative description of
the service. If possible, insert a CPT code closest to the narrative
description you have written.
iv.
Date(s) of service(s) must be indicated on the claim form and in the provider's
own record for each service billed.
v. The "MAXIMUM ALLOWANCE" as noted with
these procedure codes, "S" for specialist and "NS" for non-specialist,
represents the maximum payment for the given procedure. When submitting a
claim, the clinic must always use its usual and customary fee.
(1) Listed values for all surgical procedures
include the surgery and the follow-up care for the period indicated in days in
the column titled "Follow-Up Days."
(2) All references to time parameters shall
mean the practitioner's personal time in reference to the service rendered
unless it is otherwise indicated.
vi. Written records in substantiation of the
use of a given procedure code must be available for review and/or inspection if
requested by the New Jersey Medicaid or NJ FamilyCare fee-for-service
program.
vii. All references to
performance of any or all parts of a history or physical examination shall mean
that for reimbursement purposes these services were personally performed by a
physician, dentist, podiatrist, optometrist, certified nurse midwife,
psychologist, and other program recognized mental health professionals in a
mental health clinic, whichever is applicable. Exception: EPSDT permits the
services of a pediatric advanced practice nurse under the direct supervision of
a physician.
2.
Specific requirements concerning medicine are as follows:
i. To qualify as documentation that the
service was rendered by the practitioner during an inpatient stay, the medical
record must contain the practitioner's notes indicating that he or she
personally:
(1) Reviewed the patient's
medical history with the patient and/or his or her family, depending upon the
medical situation;
(2) Performed an
examination as appropriate;
(3)
Confirmed or revised the diagnosis; and
(4) Visited and examined the patient on the
days for which a claim for reimbursement is made.
ii. The practitioner's involvement must be
clearly demonstrated in notes reflecting his or her personal involvement with
the service rendered. This refers to those occasions when these notes are
written into the medical record by interns, residents, other house staff
members, or nurses. A counter-signature alone is not sufficient.
3. Specific requirements
concerning surgery are as follows:
i. Certain
of the listed procedures are commonly carried out as an integral part of a
total service and, as such, do not warrant a separate charge. When such a
procedure is carried out as a separate entity not immediately related to other
services, the indicated value for "separate procedure" is applicable.
4. Specific requirements
concerning radiology are as follows:
i. Values
include usual contrast media, equipment and materials.
ii. Values include consultation and written
report to the referring physician.
iii. S&I, meaning Supervision and
Interpretation, only for the procedure given. This code is used only when a
procedure is performed by more than one physician. Values include consultation
and written report.
iv. All films
taken of an area which is to be subject to a contrast study will, for
reimbursement purposes, be considered part of the contrast study unless stated
otherwise.
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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