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 10:66-6.4 - HCPCS procedure codes-qualifiers

i. Once per visit, per patient. (Not applicable if laboratory study, in any part, is performed by the clinic.)

i. Procedure code 67221 may be billed with 67225. This procedure must be rendered by ophthalmologists who are retinal specialists, and shall be limited to patients meeting the following criteria:

ii. Procedure code 67225 must be billed with 67221. This procedure must be rendered by ophthalmologists who are retinal specialists, and shall be limited to patients meeting the criteria set forth in (a)2i(1) through (3) above.

iii. Report HCPCS procedure code 67225 on the CMS 1500 claim form for procedures performed on a second eye when both eyes are treated on the same date of service. Evaluation and management (E&M) services, fluorescent angiography (FA) and other ocular diagnostic services may also be billed separately when determined medically necessary and provided on the same date of service.

iv. Modifiers LT or RT should be used on all claims for codes 67221 and 67225 whether initial or subsequent treatment.

i. Reimbursement for the above injections are on a flat-fee basis and are all inclusive for the cost of the service as well as the materials. Be advised of the following:

i. This code requires for reimbursement purposes a minimum of 50 minutes of direct personal clinical involvement with the patient or family member. The CPT narrative otherwise remains applicable.

i. Prolonged detention with or without critical care will be covered under CPT 99354 and 99355, but the service shall be consistent with the following narrative in order to be reimbursed:

ii. This code may not be used simultaneously with procedure codes that pay a reimbursement for the same time or type of service.

iii. The basis for this type of claim should be apparent on the claim form.

i. When reference is made in the CPT manual to "Office--New Patient," the intent of the Medicaid program is to consider this service as the initial visit.

ii. Reimbursement for an initial clinic visit will be disallowed, if a preventive medicine service, EPSDT examination or clinic consultation were billed within a twelve month period by a clinic.

iii. It is also to be understood that in order to receive reimbursement for an initial visit, the following minimal documentation must be on the record regardless of the setting where the examination was performed. For example:

i. Routine visit or follow-up care visit is defined for purposes of Medicaid and NJ FamilyCare fee-for-service reimbursement as the care and treatment by a physician, advanced practice nurse, or certified nurse-midwife, as appropriate, which includes those procedures ordinarily performed during a health care visit, which are dependent upon the setting and the practitioner's discipline.

ii. In order to document the record for reimbursement purposes, a progress note for the noted visits should include the following:

i. Comprehensive consultation: 99244, 99245, 99254 and 99255.

ii. Limited consultation: 99241, 99242, 99243, 99244, 99251, 99252 and 99253.

iii. Second opinion program consultation: 99244 SM.

iv. Third opinion consultation: 99244 SN.

i. Critical care is reimbursable under codes 99291 and 99292 if the service is consistent with the following:

i. If performed by an outside independent laboratory, the laboratory must submit the claim. Blood sample for lead screening test should be sent to the New Jersey State Department of Health.

ii. Procedure codes 99382 EP through 99385 EP, for initial visits, shall only be used once for the same patient during any 12-month period by the same physician, group, shared health care facility, or practitioner(s) sharing a common record. Reimbursement for these procedure codes is contingent upon submission of both a completed Report and Claim For EPSDT/HealthStart Screening and Related Procedures (MC-19) and the appropriate claim form within 30 days of the date of service. In the absence of a completed MC-19 form, reimbursement will be reduced to the level of an annual health maintenance examination.

i. The maximum fee allowance includes the removal of the subdermal contraceptive implants and the post-removal visit.

i. Primary sterilization (family planning) procedure.

ii. A completed consent form shall be attached to the claim form, in accordance with 10:66-2.3.

i. These procedures are always considered a sterilization procedure. Therefore, a completed consent form shall be attached to the claim form, in accordance with 10:66-2.3.

i. Family planning to include each of the following:

ii. Includes the cost of birth control drugs dispensed. A prescription cannot be substituted. Procedure codes with the "52" modifier do not include the cost of birth control drugs.

iii. These procedure codes (initial medical visit) will be disallowed if procedure codes 99201, 99201 FP, 99201 FP SB, 99201 FP 52, 99202, 99202 FP, 99202 FP SB, 99202 FP 52, 99203, 99203 FP, 99203 FP SB, 99203 FP 52, 99204, 99204 FP, 99204 FP SB, 99204 FP 52, 99205, 99205 FP, 99205 FP SB and 99205 FP 52 have been performed during the prior 12 months by the same provider.

i. May include pelvic examination, changes in method or physician's or certified nurse-midwife's instructions at a minimum average time of five minutes, or a visit solely for a refill supply of birth control drugs for which a prescription cannot be substituted and professional contact is not necessary.

i. May include pelvic examination or changes in method or physician's or certified nurse-midwife's instructions. This code includes the cost of birth control drugs dispensed. A prescription cannot be substituted. Procedure codes with the "52" modifier do not include the cost of birth control drugs.

i. May include pelvic examination or changes in method or physician's or certified nurse-midwife's instructions. Involves 20 or more minutes of personal time in patient contact, including documentation of time as well as adequate significant progress notes on the clinic record. This procedure code includes the cost of birth control drugs dispensed. A prescription cannot be substituted. Procedure codes with the "52" modifier do not include the cost of birth control drugs.

i. Family planning to include each of the following:

ii. This code includes the cost of birth control drugs dispensed. A prescription cannot be substituted.

iii. Procedure code 99395 FP 22 will be disallowed if procedure codes 99201, 99201 FP, 99201 FP SB, 99201 FP 52, 99202, 99202 FP, 99202 FP SB, 99202 FP 52, 99203, 99203 FP, 99203 FP SB, 99203 FP 52, 99204, 99204 FP, 99204 FP SB, 99204 FP 52, 99205, 99205 FP, and 99205 FP SB have been performed during the prior 12 months by the same provider.

i. Excision must involve the use of a scalpel and an expressor, but not an expressor alone. This code is limited to severe acne. For less than severe acne, utilize the procedure codes for routine office visits.

i. An initial procedure performed at a mental health clinic to assess a new patient and recommend an appropriate treatment plan or additional diagnostic studies. The procedure includes initial interviews with the patient and other involved individuals, conferences with referral sources, examination of written material provided by the patient or others, staff conferences and written evaluation and treatment plan including recommendations for further consultations, studies or additional information.

ii. Although this procedure may be performed by a single individual, it is expected that it should be a team approach and of one and one-half hours duration.

i. This code requires, for reimbursement purposes, a minimum of 20 to 30 minutes of direct personal clinical involvement with the patient and/or family member.

i. This code requires, for reimbursement purposes, a minimum of 45 to 50 minutes of direct personal clinical involvement with the patient and/or family member.

i. This code requires, for reimbursement purposes, a minimum of 45 to 50 minutes of direct personal clinical involvement with the patient and/or family member. The CPT narrative otherwise remains applicable.

i. This code requires, for reimbursement purposes, a minimum of 80 minutes of direct personal clinical involvement with the patient and/or family member. The CPT narrative otherwise remains applicable.

i. This code requires, for reimbursement purposes, a minimum of 25 minutes of direct personal clinical involvement with patient, family member or caretaker. The CPT narrative otherwise remains applicable.

i. This code requires, for reimbursement purposes, a minimum of 90 minutes of direct clinical involvement with the patient as a member of a group of which 10 minutes can be used for documentation. The maximum number of the group is eight and the reimbursement is per person, per group session.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

i. Antepartum care consisting of initial antepartum visits and seven subsequent antepartum visits. Specific date of all visits are to be listed on the claim form.

ii. Obstetrical delivery with in-hospital postpartum care with or without low forceps and/or episiotomy or a vaginal delivery full term or premature following completion of at least 28 weeks of gestation or if baby lives over 24 hours.

i. Vaginal delivery full term or premature following completion of at least 28 weeks of gestation or if baby lives over 24 hours.

ii. This shall also include one visit between the 15th and 60th postpartum day following delivery and out of hospital. Include name of hospital and delivery date on the claim.

i. Subsequent antepartum visit, provided as a separate procedure. Indicate specific dates of service.

i. Initial antepartum visit, provided as a separate procedure.

i. Postpartum care rendered by a physician other than delivery physician.

ii. This shall also include one visit between 15th and 60th postpartum day following delivery and out of hospital. Include name of hospital and delivery date on the claim.

i. Total obstetrical care when given by a certified nurse-midwife, including:

ii. Obstetrical delivery per vagina with or without episiotomy includes postpartum care when provided by the certified nurse-midwife in the home, birthing center or in the hospital or other inpatient setting.

i. Obstetrical delivery per vagina with or without episiotomy including postpartum care when provided by the certified nurse-midwife in the home, birthing center or in the hospital or other inpatient setting.

i. Indicate specific date of service.

i. Initial antepartum visit provided by a certified nurse-midwife provided as a separate procedure.

i. Postpartum care provided by a certified nurse-midwife who is other than the individual who performed the delivery and who is not related to this individual by any financial or contractual arrangement, e.g., group, clinic, employee, etc.

ii. One visit between the 15th and 60th postpartum day following delivery. Include delivery date on the claim provided as a separate procedure.

i. Initial antepartum visit provided by an advanced practice nurse provided as a separate procedure.

i. Routine or follow-up clinic visit. A podiatry service consisting of routine care and treatment by the podiatrist.

ii. Include significant written progress notes and office records which demonstrate positive findings and treatment changes.

i. Routine chest X-rays without medical necessity in an office (clinic) are not reimbursable under Program guidelines.

i. Pelvis X-ray is not eligible for separate payment when performed in conjunction with Complete Lumbosacral Spine X-rays (72110).

i. Procedure 73520 should be used for bilateral hip X-rays when both hips are X-rayed instead of billing separately for each hip (73500 and 73510).

i. Not eligible for separate payment when performed in conjunction with a GI or Small Bowel Series (74240, 74241, 74245, and 74250).

i. Use of the code for pelvimetry requires written evidence of medical necessity to accompany the claim.

i. Minimum time, 30 minutes. Prior authorization required.

ii. Prescribed by a licensed physician, performed by a qualified speech-language pathologist.

i. May be reimbursed when prescribed by a physician and performed by an audiologist.

ii. Tympanometry (92567) and acoustic reflex testing (92568) are reimbursable only to a specialist.

iii. Acoustic reflex testing, 92568, shall include at least two frequencies per ear. Brief reflex screening at one frequency per ear is not reimbursable. Documentation of these tests shall appear in the patient's record.

i. Individual treatment session--minimum time, 30 minutes. No more than three patients can be treated simultaneously.

ii. Prior authorization required. Consists of any one or a combination of the following modalities, prescribed by a licensed physician, performed by a qualified physical therapist and related to the patient's active treatment regimen.

i. Minimum time, 30 minutes. Prior authorization required.

ii. Prescribed by a licensed physician, performed by a qualified occupational therapist.

i. Applicable when the clinic transports a beneficiary either to or from the clinic in any one day.

ii. Reimbursement is limited to two trips per day for the same beneficiary by the same clinic.

i. Shall be billed in conjunction with Z0330 when the clinic transports a beneficiary either to or from a Partial Care program in any one day.

ii. Reimbursement is limited to two one-way trips per day for the same beneficiary, by the same clinic, to the same Partial Care program.

i. A per diem payment based on the number of days a beneficiary is supplied methadone during the billing period. This rate includes the cost of the drug, packaging, nursing time, and administrative costs.

i. Therapy with the patient and with one or more family members present. Verbal or other therapy methods are provided by a physician, or a professional counsellor under the direction of a physician, in personal involvement with the patient and the family to the exclusion of other patients and/or duties.

ii. A minimum session of one and one half hours is required with a minimum of 80 minutes personal involvement with the patient and the family and up to 10 minutes for the recording of data.

iii. The clinic may bill only for the patient and not for other family members.

i. Meeting with the family or other significant persons to interpret or explain medical, psychiatric or psychological examinations and procedures, other accumulated data and/or advice to the family or other significant persons on how to assist the patient.

ii. A minimum of 50 minutes of personal involvement with the family is required. The clinic may bill only for the patient and not for other family members.

i. Therapy with the patient and with one or more family members present. Verbal or other therapy methods are provided by a physician, or a professional counsellor under the direction of a physician, in personal involvement with the patient and the family to the exclusion of other patients and/or duties.

ii. A minimum session of one and one half hours is required with a minimum of 80 minutes personal involvement with the patient and the family and up to 10 minutes for the recording of data.

iii. The clinic may bill only for the patient and not for other family members.

i. Meeting with the family or other significant persons to interpret or explain medical, psychiatric or psychological examinations and procedures, other accumulated data and/or advice to the family or other significant persons on how to assist the patient.

ii. A minimum of 50 minutes of personal involvement with the family is required. The clinic may bill only for the patient and not for other family members.

i. A visit with a physician for review and evaluation of the medication history of the patient and the writing, or renewal of prescription, as necessary.

i. Verbal, drug augmented, or other therapy methods provided by a physician, or a professional counsellor under the direction of a physician, in a personal involvement with one patient to the exclusion of other patients and/or duties.

ii. A minimum of 50 minutes personal involvement with the patient is required. This includes a prescription visit when necessary.

i. Verbal or other therapy methods provided by one or more physicians, or professional counsellors under the direction of physician, in a personal involvement with two or more patients, with a maximum of eight patients.

ii. A minimum session of one and one half hours is required. This includes preparation time in addition to the one and one half hours session time.

i. Psychometric and/or projective tests with a written report.

ii. To be used only by a substance use disorder treatment facility specifically approved by the Program to provide this service.

i. A per diem payment based on the number of days a beneficiary is supplied methadone during the billing period. This rate includes the cost of the drug, packaging, nursing time, and administrative costs.

i. Verbal, drug augmented, or other therapy methods provided by a physician, or a professional counsellor under the direction of a physician in a personal involvement with one patient to the exclusion of other patients and/or duties.

ii. A minimum of 25 minutes personal involvement with the patient is required. This includes a prescription visit when necessary.

i. To determine what level, if any, a drug is present in the urine.

ii. To be used only by a drug treatment center specifically approved by the Program to provide this service.

i. Once per visit per patient. Not applicable if lab study, in any part, is to be performed by the clinic.

i. Therapy with the patient and with one or more family members present. Verbal or other therapy methods are provided by a physician, or a professional counselor under the direction of a physician, in personal involvement with the patient and the family to the exclusion of other patients and/or duties.

ii. A minimum session of one and one half hours is required with a minimum of 80 minutes personal involvement with the patient and the family and up to 10 minutes for the recording of data.

iii. The clinic shall bill only for the patient and not for other family members.

i. Meeting with the family or other significant persons to interpret or explain medical, psychiatric or psychological examinations and procedures, other accumulated data and/or advice to the family or other significant persons on how to assist the patient.

ii. A minimum of 50 minutes of personal involvement with the family is required. The clinic shall bill only for the patient and not for other family members.

i. A visit with a physician for review and evaluation of the medication history of the patient and the writing or renewal of prescription, as necessary.

i. Verbal, drug augmented, or other therapy methods provided by a physician, or a professional counselor under the direction of a physician, in a personal involvement with one patient to the exclusion of other patients and/or duties.

ii. A minimum of 50 minutes personal involvement with the patient is required. This includes a prescription visit when necessary.

i. Verbal or other therapy methods provided by one or more physicians, or professional counselors under the direction of physician, in a personal involvement with two or more patients, with a maximum of eight patients.

ii. A minimum session of one and one-half hours is required. This includes preparation time in addition to the one and one half hours session time.

i. Psychometric and/or projective tests with a written report are included in the reimbursement.

ii. To be used only by a substance use disorder treatment facility specifically approved by the WFNJ/SAI Program to provide this service.

i. See N.J.A.C. 10:66-2.16; FD-179 form shall be attached to the claim form.

ii. For claims submitted by ambulatory surgical centers only, the trimester of pregnancy shall be identified on the claim form by using modifier UA for first trimester or UB for second trimester.