New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 67 - PSYCHOLOGICAL SERVICES
Subchapter 3 - CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODE AND MAXIMUM FEE SCHEDULE FOR PSYCHOLOGICAL SERVICES
Section 10:67-3.1 - Introduction

Universal Citation: NJ Admin Code 10:67-3.1

Current through Register Vol. 56, No. 6, March 18, 2024

(a) The New Jersey Medicaid and NJ FamilyCare programs adopted the Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 1320d et seq., and incorporated herein by reference, as amended and supplemented and published by PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010. Revisions to the Healthcare Common Procedure Coding System made by CMS (code additions, code deletions and replacement codes) will be reflected in this chapter 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.SA. 52:14B-1 et seq. The HCPCS Level I codes consist of the American Medical Association (AMA) Current Procedural Terminology (CPT) codes, which are assigned to specific procedures by the AMA. HCPCS Level II codes are assigned to specific procedures by CMS. An updated copy of the CPT 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 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.

1. The use of a procedure code will be interpreted by the New Jersey Medicaid/NJ FamilyCare program as a representation that the psychologist personally furnished, as a minimum, the service for which it stands.

(b) When submitting a claim, the psychologist must always use his or her usual and customary fee. The MAXIMUM FEE ALLOWANCE designated for any HCPCS code represents the New Jersey Medicaid/NJ FamilyCare program's maximum payment for the given procedure.

1. All references to time parameters shall mean the psychologist's personal time in reference to the service rendered unless it is otherwise indicated.

2. The information under the "QUALIFIER" refers the provider to information concerning the New Jersey Medicaid/NJ FamilyCare program qualifications and requirements when a procedure or services code is used.

(c) The psychological services use exclusively Level I HCPCS codes of a two-level coding system, as follows:

1. Level I codes: Narratives for these codes are found in CPT, which is incorporated herein by reference, as amended and supplemented. The codes are adapted from CPT for use primarily by the psychologist. Level I procedure codes, and fees for each, for which the psychologist may bill, can be found at 10:67-3.2.

(d) Specific elements of HCPCS codes require the attention of providers. The lists of HCPCS code numbers for psychologist 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:

1. 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 ("IND" column) and as modifiers ("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.
i. These symbols and/or letters shall not be ignored, because they reflect requirements, in addition to the narrative which accompanies the CPT/HCPCS procedure code as written in the CPT, for which the provider is liable. These additional requirements shall be fulfilled before reimbursement is requested.

ii. If there is no identifying symbol listed, the CPT/HCPCS procedure code narrative prevails.

ii. If there is no identifying symbol listed, the CPT/ HCPCS procedure code narrative prevails.

INDlists alphabetic symbols used to refer the provider to information concerning the New Jersey Medicaid/NJ FamilyCare program's qualifications and requirements when a procedure or service code is used. An explanation of the indicators and qualifiers used in this column is located below and in paragraph 1, "Alphabetic and numeric symbols," as follows:
"P" =preceding any procedure code indicates that prior
authorization shall be required. The appropriate form
that must be used to request prior authorization is
indicated in the Fiscal Agent Billing Supplement.
"N" =preceding any procedure code means that qualifiers are
applicable to that code. (See also 10:67-2.3
for the specific limitations of the total dollar
amounts for services within a specific timeframe for a
specific Medicaid/NJ FamilyCare beneficiary.)
HCPCS CODE =HCPCS procedure code numbers.
MOD =Alphabetic and numeric symbols: Under certain
circumstances, services and procedures may be modified
by the addition of alphabetic and/or numeric
characters at the end of the code.
22" ="Unusual Services: When the service(s) provided is
greater than that usually required for the listed
procedure, it may be identified by adding the modifier
"22" to the usual procedure number. A report with
additional documentation must accompany the claim form
to justify the greater services, unusual services or
complications.
HA = Services provided in child and/or adolescent treatment program.

(e) Listed below are general policies of the New Jersey Medicaid/NJ FamilyCare program that pertain to HCPCS. Specific information concerning the responsibilities of a psychologist when rendering Medicaid/NJ FamilyCare-covered services and requesting reimbursement are located at 10:67-1.4, Recordkeeping; 10:67-1.5, Basis of reimbursement; and N.J.A.C. 10:67-2, General provisions.

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. When billing, the provider must enter on the claim form a CPT/HCPCS procedure code as listed in 10:67-3.2.

iii. Date(s) of service(s) must be indicated on the claim form and in the provider's own record for each service billed.

iv. The "MAXIMUM FEE ALLOWANCE" as noted with these procedure codes represents the maximum payment for the given procedure for the psychologist and psychologist specialist. When submitting a claim, the psychologist must always use her or his usual and customary fee.

v. The use of a procedure code will be interpreted by the New Jersey Medicaid/NJ FamilyCare program as evidence that the practitioner personally furnished, as a minimum, the services for which it stands.

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