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 10:66-6.5 - HealthStart
Universal Citation: NJ Admin Code 10:66-6.5
Current through Register Vol. 56, No. 18, September 16, 2024
(a) HealthStart Maternity Care code requirements are as follows:
1. Separate reimbursement shall be available
for Maternity Medical Care Services and Maternity Health Support
Services.
2. Maternity Medical Care
Services shall be billed as a total obstetrical package when feasible, but may
also be billed as separate services.
3. The enhanced reimbursement (that is,
HealthStart procedure codes) for delivery and postpartum care shall be claimed
only for a patient who received at least one antepartum HealthStart Maternity
Medical or Health Support Service.
4. The modifier "SB" in the HCPCS lists of
codes refers to those services provided by certified nurse midwives; include
the modifier at the end of each code.
5. Laboratory, other diagnostic procedures,
and all necessary medical consultations are eligible for separate
reimbursement.
i. Laboratory procedures
performed by an outside laboratory shall be reimbursed to the laboratory. The
clinic may submit a claim for a venipuncture using procedure code 36415 when
necessary to collect blood specimens.
6. HealthStart Maternity Medical Care
Services codes are as follows:
(b) HealthStart Pediatric Preventive Care code requirements are as follows:
1.
HealthStart Pediatric Care Guidelines provide for up to nine preventive child
health visits for a child under two years of age.
i. All preventive child health visits shall
be billed using the HealthStart Preventive Child Health Visit codes appropriate
to the child's age at the time of visit. Each preventive child health visit
HCPCS procedure code may be claimed only once per child.
ii. Claims shall be submitted using Form
MC-19, EPSDT/HealthStart Screening and Related Procedures.
2. Laboratory, other diagnostic procedures,
and all necessary medical consultations shall be eligible for separate
reimbursement.
i. Laboratory procedures
performed by an outside laboratory shall be reimbursed to the laboratory. The
clinic may submit a claim for a venipuncture using procedure code 36415 when
necessary to collect blood specimens.
3. HealthStart Pediatric Preventive Care
codes represent visits based on an infant's age according to the following
schedule:
4. A
HealthStart Pediatric Preventive Care Visit includes the following elements:
i. History including behavior and
environmental factors;
ii.
Developmental assessment; and
iii.
Complete, unclothed physical examination by a physician or an advanced practice
nurse under the personal supervision of a physician, to include:
(1) Measurements: height, weight and head
circumference;
(2) Vision and
hearing screening; and
(3)
Nutritional assessment.
iv. Assessment and administration of
immunizations (see appropriate HCPCS procedure codes for reimbursement
amounts);
v. Anticipatory
guidance;
vi. Arrangement for
diagnosis and treatment of medical problems uncovered during the visit. This
includes self-referrals and/or referrals to other providers, as medically
indicated;
vii. Appropriate
laboratory procedures performed, or referred, in accordance with HealthStart
Pediatric Care Guidelines.
(1) Sickle cell,
PKU screening, as appropriate;
(2)
Hemoglobin or hematocrit twice, at six to nine months and 20 to 24 months of
age;
(3) Urinalysis, twice: at six
to nine months and 20 to 24 months of age;
(4) Tuberculin test, twice: at 12 to 14
months and 20 to 24 months; and
(5)
Lead screening at six to 12 months and annually thereafter, or more often if
clinically indicated.
viii. Case coordination: referral for
nutritional, psychological, social and other community services, as
appropriate; provision or arrangement for 24-hour telephone physician access
and sick care; and outreach and follow-up activities in accordance with the
HealthStart Pediatric Care Guidelines.
NOTE: As indicated in N.J.A.C. 10:66-2.4(b), laboratory procedures performed by a clinic are reimbursable to the clinic; if such procedures are performed by an outside laboratory, the laboratory shall submit a separate claim.
NOTE: As indicated in N.J.A.C. 10:66 Appendix, as referenced in N.J.A.C. 10:66-1.1(e), claims for HealthStart Preventive Care visits shall include a completed Health Insurance Claim Form, CMS 1500, and a HealthStart Preventive Child Health Form.
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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