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. 6, March 18, 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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