Current through Register Vol. 56, No. 6, March 18,
2024
(a) Nothing in this
subchapter shall compel the PIP insurer or a motor bus insurer to pay more for
any service or equipment than the usual, customary and reasonable fee, even if
such fee is well below the automobile insurer's or motor bus insurer's limit of
liability as set forth in the fee schedules. Insurers are not required to pay
for services or equipment that are not medically necessary.
1. The fees for physicians' services in
subchapter Appendix, Exhibit 1, the provisions in (f)1 through 7 below and the
non-physician facility fees in subchapter Appendix, Exhibit 7 shall not apply
to trauma services at Level I and Level II trauma hospitals. Bills for services
subject to the trauma services exemption shall use the modifier
"-TS".
2. The non-physician
facility fees in subchapter Appendix, Exhibit 7 shall not apply to services
provided in hospital emergency rooms. The bills for these services shall use
the modifier "-ER".
3. The
physician fees for surgical services (CPT 10000 though 69999) provided in
emergency care in acute care hospitals that are not subject to the trauma care
exemption shall be reimbursed at 150 percent of the physicians' fees in
subchapter Appendix, Exhibit 1. The bills for these services shall use the
modifier "-ER".
4. Except as
provided in (a)1 through 3 above, the fees in Appendix, Exhibits 1 through 7
apply regardless of the site of service.
(b) The region used to determine the proper
fee set forth in the schedules shall be determined by the region in which the
services were rendered or the equipment was provided or, in the case of
elective services or equipment provided to New Jersey residents outside the
State, by the region in which the insured resides.
(c) The fees set forth in the schedule for
durable medical equipment, subchapter Appendix, Exhibit 5, are retail prices,
which may include purchase prices for both new and used equipment, and/or
monthly rentals. New equipment shall be distinguished with the use of
modifier-NU, used equipment with modifier-UE and rental equipment with
modifier-RR.
1. The insurer's total limit of
liability for the rental of a single item of durable medical equipment set
forth in the schedule is 15 times the monthly rental fee or the purchase price
of the item, whichever is less.
2.
For the provision and billing of durable medical equipment, payors shall follow
the relevant provisions of Chapter 20 of the Medicare Claims Processing Manual,
updated periodically by CMS and incorporated by reference, that were in effect
at the time the service was provided (
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c20.pdf).
(d) The insurer's limit of
liability for any medical expense benefit for service or equipment provided
outside the State of New Jersey shall be as follows:
1. When the service or equipment is provided
by reason of emergency or medical necessity, the reasonable and necessary costs
shall not exceed fees that are usual, customary and reasonable for that
provider in the geographic location where the service or equipment is
provided.
2. When the service or
equipment is provided by reason of the election by the insured to receive
treatment outside the State of New Jersey, the reasonable and necessary costs
shall not exceed fees set forth in the fee schedules for the geographic region
in which the insured resides.
(e) Except as noted in (e)1 through 3 below,
the insurer's limit of liability for any medical expense benefit for any
service or equipment not set forth in or not covered by the fee schedules shall
be a reasonable amount considering the fee schedule amount for similar services
or equipment in the region where the service or equipment was provided or, in
the case of elective services or equipment provided outside the State, the
region in which the insured resides. When a CPT, CDT, or HCPCS code for the
service performed has been changed since the fee schedule rule was last
amended, the provider shall always bill the actual and correct code found in
the most recent version of the American Medical Association's Current
Procedural Terminology or the American Dental Association's Current Dental
Terminology. The amount that the insurer pays for the service shall be in
accordance with this subsection. Where the fee schedule does not contain a
reference to similar services or equipment as set forth in the preceding
sentence, the insurer's limit of liability for any medical expense benefit for
any service or equipment not set forth in the fee schedules shall not exceed
the usual, customary and reasonable fee.
1.
For the purposes of this subchapter, determination of the usual, reasonable and
customary fee means that the provider submits to the insurer his or her usual
and customary fee by means of explanations of benefits from payors showing the
provider's billed and paid fee(s). The insurer determines the reasonableness of
the provider's fee by comparison of its experience with that provider and with
other providers in the region. National databases of fees, such as those
published by FAIR Health (
www.fairhealthus.org) or Wasserman
(
http://www.medfees.com/), for
example, are evidence of the reasonableness of fees for the provider's
geographic region or ZIP code. The use of national databases of fees is not
limited to the above examples. When using a database as evidence of the
reasonableness of a fee, the insurer shall identify the database used, the
edition date, the geozip, and the percentile.
2. All applicable provisions of this section
concerning billing and payment apply to fees for services provided outside of
New Jersey and to fees that are not on the fee schedule.
3. Codes in Appendix, Exhibit 1 that do not
have an amount in the ASC facility fee column are not reimbursable if performed
in an ASC and are not subject to the provision in (e) above concerning services
not set forth in or covered by the fee schedules.
(f) Except as specifically stated to the
contrary, the following shall apply to physician charges for multiple and
bilateral surgeries (CPT 10000 through 69999), co-surgeries and assistant
surgeons:
1. For multiple surgeries, rank the
surgical procedures in descending order by the fee amount, using the fee
schedule or UCR amount, as appropriate. The highest valued procedure is
reimbursed at 100 percent of the eligible charge. Additional procedures are
reported with the modifier "-51" and are reimbursed at 50 percent of the
eligible charge. If any of the multiple surgeries are bilateral surgeries using
the modifier "-50," consider the bilateral procedure at 150 percent as one
payment amount, rank this with the remaining procedures, and apply the
appropriate multiple surgery reductions.
2. There are two types of procedures that are
exempt from the multiple procedure reduction. Codes in CPT that have the note,
"Modifier -51 exempt" shall be reimbursed at 100 percent of the eligible
charge. In addition, some related procedures are commonly carried out in
addition to the primary procedure. These procedure codes contain a specific
descriptor that includes the words, "each additional" or "list separately in
addition to the primary procedure." These add-on codes cannot be reported as
stand-alone codes but when reported with the primary procedure are not subject
to the 50 percent multiple procedure reduction.
3. The terminology for some procedure codes
includes the terms "bilateral" or "unilateral or bilateral." The payment
adjustment rules for bilateral surgeries do not apply to procedures identified
by CPT as "bilateral" or "unilateral or bilateral" since the fee schedule
reflects any additional work required for bilateral surgeries. If a procedure
is not identified by its terminology as a bilateral procedure (or unilateral or
bilateral) and is performed bilaterally, providers must report the procedure
with modifier "-50" as a single line item. Reimbursement for bilateral
surgeries reported with the modifier "-50" shall be 150 percent of the eligible
charge.
4. For co-surgeries, each
surgeon bills for the procedure with a modifier "-62". For co-surgeries
(modifier 62), the fee schedule amount applicable to the payment for each
co-surgeon is 62.5 percent of the eligible charge.
5. The eligible charge for medically
necessary assistant surgeon expenses shall be 20 percent of the primary
physician's allowable fee determined pursuant to the fee schedule and rules.
Assistant surgeon expenses shall be reported using modifier -80, -81 or -82 as
designated in CPT. When the assistant surgeon is someone other than a physician
surgeon, the reimbursement shall not exceed 85 percent of the amount that would
have been reimbursed had a physician surgeon provided the service.
Non-physician assistant surgeon services shall be reported using
modifier-AS.
6. The necessity for
co-surgeons and assistant surgeons for an operation shall be determined by
reference to authorities such as the Medicare physician fee schedule database
(
www.cms.gov). Fees for assistant
surgeons and co-surgeons are not rendered eligible for reimbursement simply
because it is the policy of a provider or an outpatient surgical facility that
one be present.
7. It is the
responsibility of providers that are acting as co-surgeons or assistant
surgeons to include the correct modifier in their bills, especially as they may
not be submitted to the insurer at the same time. If a surgeon submits a bill
without a modifier and is paid 100 percent of the eligible charge and the
insurer subsequently receives a bill from a co-surgeon or assistant surgeon for
the same procedure, the insurer shall notify both providers that it has already
paid 100 percent of the eligible charge and that it cannot reimburse the
co-surgeon or assistant surgeon until the overpayment has been offset or
refunded.
8. Prosthetic and other
devices, including neuro-stimulators, internal/external fixators, single use
spine wands and spine probes, tissue grafts, plates, screws, anchors and wires,
whether implanted, inserted, or otherwise applied by covered surgical
procedures shall be reimbursed at no more than the invoice for the device plus
20 percent. This provision applies regardless of where the procedure is
performed, including trauma centers, hospital emergency rooms, inpatient
surgeries and outpatient surgical facilities.
(g) Except as specifically stated to the
contrary in this subchapter, the fee schedules shall be interpreted in
accordance with the following, incorporated hererin by reference, as amended
and supplemented: the relevant chapters of the Medicare Claims Processing
Manual, updated periodically by CMS, that were in effect at the time the
service was provided. The Medicare Claims Processing Manual is available at
https://www.cms.gov/Manuals/IOM/itemdetail.asp?itemID=CMS018912;
the NCCI Policy Manual for Medicare Services, as updated periodically by CMS
and available at
http://www.cms.gov/NationalCorrectCodInitEd/Downloads/NCCI_Policy_Manual.zip;
Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service,
available from CMS at
https://www.cms.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf; and the
CPT Assistant available from the American Medical Association (www.AMAbookstore.com).
1. Artificially separating or partitioning
what is inherently one total procedure into subparts that are integral to the
whole for the purpose of increasing medical fees is prohibited. Such practice
is commonly referred to as "unbundling" or "fragmented" billing. Providers and
payors shall use the National Correct Coding Initiative (NCCI) Edits,
incorporated herein by reference, as updated quarterly by CMS and available at
http://www.cms.hhs.gov/NationalCorrectCodInitEd/.
Modifier 59 and other NCCI-associated modifiers should not be used to bypass an
NCCI edit unless the proper criteria for use of the modifier are met.
Documentation in the medical record must satisfy the criteria required by any
NCCI-associated modifier used. For more information on the criteria for the use
of modifiers, see the NCCI Policy Manual and Modifier 59 Article referenced in
(g) above.
2. CPT 97010
(application of hot/cold packs) is bundled into the payment for other services
and shall not be reimbursed separately.
3. X-ray digitization or computer aided
radiographic mensuration reported under CPT 76499 or any other code are not
reimbursable under PIP.
4. Kinesio
taping or other taping is not reimbursable under PIP. Kinesio taping shall not
be billed using the strapping codes, CPT 29200 through 29280 and 29520 through
29590.
5. Platelet Rich Plasma
(PRP) injections are only reimbursable for treatment of chronically injured
tendons that have failed to improve despite appropriate conservative
treatments. PRP injections shall be billed under code 0232T in subchapter
Appendix, Exhibit 1.
6. Leads,
pads, batteries and any other supplies for use of TENS or EMS devices are
included in the fee for the rental of the unit and are not separately
reimbursable when rented. For purchase of the unit, the first month's supply of
leads, pads, batteries and any other supplies for TENS or EMS units are
included.
7. The eligible charge
for an office visit includes reviewing the report of an imaging study when the
provider of the imaging study has billed for the technical and professional
component of the service. In these circumstances, it is not appropriate for the
provider to bill for an office visit, CPT 76140 or for the physician component
of the imaging study. CPT 76140 is not reimbursable. Where a provider in a
different practice or facility performs a medically necessary review of an
imaging study and produces a written report as part of a consultation, the
provider shall bill the professional component (modifier -26) for each specific
radiology service.
8. When CPT
77003, fluoroscopic guidance, can be billed separately and is not included as
part of another procedure, it is reimbursable only per spinal region, not per
level.
9. HCPCS code G0289 is an
add-on code and should be added to the knee arthroscopy code for the major
procedure being performed. This code is only to be reported once per extra
compartment, even if chondroplasty, loose body removal and foreign body removal
are all performed. The code may be reported twice if the physician performs
these procedures in two compartments in addition to the compartment where the
main procedure was performed.
i. This code
shall be reported only when the physician spends at least 15 minutes in the
additional compartment performing the procedure. It shall not be reported if
the reason for performing the procedure is due to a problem caused by the
arthroscopic procedure itself. This code is to be used when a procedure is
performed in the lateral, medial, or patellar compartments in addition to the
main procedure. The billing of CPT codes 29874 and 29877 is not permitted with
other arthroscopic procedures on the same knee and CPT code 29874 shall not be
used to report the services described by code G0289.
10. Appendix J of the CPT manual,
Electrodiagnostic Medicine Listing of Sensory, Motor and Mixed Nerves may be
used as a reference for the appropriate reimbursement of this type of
Electrodiagnostic testing.
11.
Moderate (conscious) sedation performed by the physician who also furnishes the
medical or surgical service cannot be reimbursed separately for the procedures
listed in Appendix G of the CPT manual. In that case, payment for the sedation
is bundled into the payment for the medical or surgical service. As a result,
CPT codes 99143 through 99145 are not reimbursable for the procedures in
Appendix G of the CPT manual.
12.
CPT codes 99148 through 99150 are only reimburseable when a second physician
other than the provider performing the diagnostic or therapeutic services
provides moderate sedation in a facility setting (for example, hospital,
outpatient hospital/ambulatory surgery center or skilled nursing facility). CPT
codes 99148 through 99150 are not reimburseable for services performed by a
second physician in a physician office, freestanding imaging center or for any
procedure code identified in CPT as including moderate (conscious)
sedation.
13. CPT 22505,
"Manipulation of spine requiring anesthesia, any region," if medically
necessary, can only be reported once for any and all regions manipulated on
that date.
(h) To be
reimbursable, nerve conduction studies (NCS) (CPT 95900 - 95904) must be
interpreted by a provider who was on site and directly supervised or performed
the nerve conduction study in accordance with
N.J.A.C.
13:35-2.6(n)3. Needle
Electromyography (EMG) interpretation must be performed in the same facility on
the same day by the same physician who performed and/or supervised the needle
EMG.
(i) The reporting of nerve
conduction studies and needle electromyography (EMG) (CPT 95860 through 95872)
results should be integrated into a unified diagnostic impression. Separate
reports for needle EMG and NCS are not reimbursable under the codes above in
this subsection.
(j) For surgery
and many other procedures, it is established practice to include follow-up care
and visits as part of the basic procedure charge. Such charges shall not be
subject to additional billings. The existence of a CPT code, per se, does not
imply the right to receive separate compensation for the
procedure/sub-procedure so described. If a procedure is judged to be part of
the primary procedure, only the charges for the primary procedure are eligible.
As identified in CPT, separate procedures are commonly carried out as an
integral part of another procedure. They shall not be billed in conjunction
with the other procedure, but may be billed when performed independently of the
other procedure.
(k) CPT codes for
procedures described in CPT as "unlisted procedure" or "unlisted service"
(example: 64999 Unlisted procedure nervous system) are not reimbursable without
documentation from the provider describing the procedure or service performed,
demonstrating its medical appropriateness and indicating why it is not
duplicative of a code for a listed procedure or service. Documentation may
include the existence of temporary or AMA Category III or HCPCS codes for the
procedure or information in the AMA CPT Assistant publication. In submitting
bills for unlisted codes, the provider should base the fee on a comparable
procedure. It is never appropriate for the provider to bill an unlisted code
for a list of services that have CPT codes. Providers that intend to use
unlisted codes in non-emergency situations are encouraged to notify the insurer
in advance through the precertification process. Based on the information
submitted by the provider, the insurer shall determine whether the CPT coding
is appropriate.
(l) Certain CPT
codes are listed in the fee schedule with three entries. There is a global fee
with no modifier, a technical component with modifier "TC" and a physician
component with modifier "-26". Services with physician component amounts of
zero in the fee schedule are considered to be 100 percent technical. A provider
shall not bill the global fee and a technical or physician component. The
technical or physician component shall be billed when only that part of the
service is being provided.
(m) The
daily maximum allowable fee shall be $ 105.00 for the Physical Medicine and
Rehabilitation CPT codes listed in subchapter Appendix, Exhibit 6, incorporated
herein by reference, that are commonly provided together. The daily maximum
applies when such services are performed for the same patient on the same date.
In determining whether a provider has reached the daily maximum, the insurer
shall apply the NCCI edits. The daily maximum applies to all providers,
including dentists. However, when the provider can demonstrate that the
severity or extent of the injury is such that extraordinary time and effort is
needed for effective treatment, the insurer shall reimburse in excess of the
daily maximum. Such injuries could include, but are not limited to, severe
brain injury and non-soft-tissue injuries to more than one part of the body.
Such injuries would not include diagnoses for which there are care paths in
N.J.A.C. 11:3-4. Treatment that the provider believes should not be subject to
the daily maximum shall be billed using modifier -22 as designated in CPT for
unusual procedural services. Unless already provided to the insurer as part of
a decision point review or precertification request, the billing shall be
accompanied by documentation of why the extraordinary time and effort for
treatment was needed.
1. Supervised
modalities and those therapeutic procedures that do not list a specific time
increment in their description shall be limited to one unit per day.
2. CPT 97012 is the appropriate code for
billing powered traction therapy.
3. CPT 97026 is the appropriate code for
billing cold or low-powered laser therapy.
4. HPCPS code G0283 is the appropriate code
for billing unattended electrical stimulation.
5. Pursuant to
N.J.S.A.
39:6A-4, physical therapy, as defined in
N.J.S.A.
45:9-37.13, shall not be reimbursable under
PIP unless rendered by a licensed physical therapist pursuant to a referral
from a licensed physician, dentist, podiatrist or chiropractor within the scope
of the respective practices.
(n) Follow-up evaluation and management
services for the re-examination of an established patient shall be reimbursed
in addition to physical medicine and rehabilitation procedures only when any of
the circumstances set forth in (n)1 through 4 below is present and not more
than twice in any 30-day period. Modifier -25 shall be added to an evaluation
and management service when a significant separately identifiable evaluation
and management service is provided and documented as medically necessary as
follows:
1. There is a definite measurable
change in the patient's condition requiring significant change in the treatment
plan;
2. The patient fails to
respond to treatment, requiring a change in the treatment plan;
3. The patient's condition becomes permanent
and stationary, or the patient is ready for discharge; or
4. It is medically necessary to provide
evaluation services over and above those normally provided during the
therapeutic services.
(o) Regardless of the specific codes that are
included in a DPR/Precertification request, the insurer's reimbursement for
those services shall be consistent with the rules contained in this subchapter,
including the NCCI edits and the CPT Manual current at the time the services
were provided.
(p) The ANES code on
the Physicians' Fee Schedule is the conversion factor for anesthesia units.
Payors shall follow the Medicare Claims Processing Manual and other guidelines
for calculating the number of units for the various CPT codes for the
administration of anesthesia and other billing situations, such as directing or
supervising Certified Nurse Anesthetists and other non-physician anesthesia
providers. These can be found at:
www.cms.hhs.gov/center/anesth.asp.