Current through Register Vol. 56, No. 18, September 16, 2024
(a) The New Jersey Medicaid/NJ FamilyCare
programs use the Centers for Medicare and 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 may contain
alphabetic characters.
(b) HCPCS is
a two-level coding system, as follows:
1.
LEVEL I CODES (narratives found in the CPT): These codes are adapted from the
Physicians Current Procedural Terminology, as amended and supplemented,
published by the American Medical Association, 515 N. State Street, Chicago, IL
60610, incorporated herein by reference. The CPT codes are used primarily by
physicians, podiatrists, optometrists, certified nurse-midwives, advanced
practice nurses, independent clinics and independent laboratories. Copyright
restrictions make it impossible to print substantial excerpts from CPT
procedure narratives for Level I codes. Thus, in order to determine those
narratives, it is necessary to refer to the CPT.
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) Regarding specific elements of
HCPCS codes, which require the attention of providers, the lists of HCPCS code
numbers for services are arranged in tabular form with specific information for
a code given under columns with titles, such as "HCPCS Code," "DESCRIPTION" and
"MAXIMUM FEE ALLOWANCE." The information given under each column is summarized
below:
1. "HCPCS Code"--Lists the HCPCS
procedure code numbers;
2.
"DESCRIPTION--Code narrative: Complete narratives for the codes are found at
10:77A-2.2;
3. "MAXIMUM FEE ALLOWANCE"--Lists the New
Jersey Medicaid/NJ FamilyCare programs' maximum fee allowance schedule. If the
symbol "B.R." (By Report) is listed instead of a dollar amount, it means that
additional information will be required in order to properly evaluate the
service. Attach a copy of the report to the claim form. If the symbol "N.A."
(Not Applicable) is listed instead of a dollar amount, it means that the
service is not reimbursable.
(d) 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.
1. Providers shall
consider these symbols and letters when billing because the symbols/letters
reflect requirements, in addition to the narrative that accompanies the
CPT/HCPCS procedure code, for which the provider is liable. These additional
requirements shall be fulfilled before reimbursement is requested.
i. "52" Reduced Services: Under certain
circumstances a service or procedure is partially reduced or modified. Under
these circumstances the service provided can be identified by its usual
procedure number and the addition of the modifier '52,' signifying that the
service is reduced or modified. This provides a means of reporting reduced
services without disturbing the identification of the basic service. In this
chapter, the "52" modifier indicates that AMHR services are rendered in a
supervised apartment setting rather than in a group home setting.
(e) The general and
specific requirements of the New Jersey Medicaid/NJ FamilyCare programs that
pertain to HCPCS follow:
1. When filing a
claim, the appropriate HCPCS Codes shall be used in conjunction with modifiers,
when applicable;
2. The use of a
procedure code shall be interpreted by the New Jersey Medicaid/NJ FamilyCare
programs as evidence that the provider furnished, as a minimum, the service for
which it stands;
3. When billing,
the provider shall enter onto a CMS 1500 claim form, a CPT/HCPCS procedure code
as listed in CPT or in this subchapter.
4. Date(s) of service(s) shall be indicated
on the claim form and in the provider's own record for each service
billed;
5. The "MAXIMUM FEE
ALLOWANCE" as noted with these procedure codes represents the maximum amount a
provider will be reimbursed for the given procedure;
i. All references to time parameters shall
mean the provider's personal time in reference to the service rendered, unless
otherwise indicated. These procedure codes are all-inclusive for all procedures
provided during that time;
6. Written records in substantiation of the
use of a given procedure code shall be available for review and/or inspection
if requested by the Division of Medical Assistance and Health Services, the
Department of Human Services, or any contracted and authorized agent of the
Department.
