New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 76 - PROGRAMS OF ASSERTIVE COMMUNITY TREATMENT (PACT) SERVICES
Subchapter 3 - PROCEDURE CODES FOR REIMBURSEMENT
Section 10:76-3.1 - Introduction

Universal Citation: NJ Admin Code 10:76-3.1

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

(a) The New Jersey Medicaid/NJ FamilyCare programs utilize the Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS). HCPCS follows the American Medical Association's Physicians' Current Procedural Terminology (CPT) architecture, employing a five-position code and as many as two 2-position modifiers. The CPT is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical procedures and services performed by physicians. Unlike the CPT numeric design, the CMS assigned codes and modifiers contain alphabetic characters. The New Jersey Medicaid/NJ FamilyCare program adopted the Centers for Medicare and Medicaid Services Healthcare Common Procedure Coding System codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, 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, 52:14B-1 et seq.

(b) HCPCS is a two-level coding system:

1. LEVEL I CODES (narratives found in CPT): These codes are adapted from the Current Procedural Terminology (CPT), incorporated herein by reference, and are utilized primarily by physicians, podiatrists, optometrists, certified nurse-midwives, certified nurse practitioners/clinical nurse specialists, independent clinics and independent laboratories. Copies of the CPT may be obtained from the American Medical Association, 515 North State Street, Chicago, IL 60610.

2. LEVEL II CODES: The narratives for Level II codes are found in this subchapter. These codes are not found in the CPT and are assigned by CMS for use by physicians and other practitioners.

(c) The lists of HCPCS code numbers for rehabilitative services are arranged in tabular form with specific information for a code given under columns with the following titles:

1. "IND "--lists the indicators that define requirements to be met when using the HCPCS codes.
i. "P" indicates that prior authorization is required;

2. "HCPCS Code"--Lists the HCPCS procedure code numbers;

3. "DESCRIPTION"--Code narrative: Narratives for Level III codes are found at 10:76-3.2;

4. "MAXIMUM FEE ALLOWANCE" - Lists the New Jersey Medicaid/NJ FamilyCare programs maximum fee allowance schedule. The maximum fee allowance associated with a procedure code represents the maximum amount a provider will be reimbursed for the given procedure; and

5. "MOD" services and procedures may be modified under certain circumstances. When applicable, the modifying circumstances are identified by the addition of a two-digit code following the HCPCS procedure number. The New Jersey Medicaid/NJ FamilyCare program's recognized modifier codes for PACT services are as follows:

22: Unusual Services: When the services provided are greater than that usually required for the listed procedure, it may be identified by adding 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.

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