10:54-9.8 HCPCS Procedure Codes with Qualifiers (except forPathology/Laboratory)
(a) The following is a list of Level I HCPCS procedure codes with their associated qualifiers (except for Pathology and Laboratory procedure codes). Providers are to recognize the requirements inherent in billing each of the HCPCS. The qualifiers related to Pathology/Laboratory Services are located in the next section in N.J.A.C. 10:54-9.9. FOR A LISTING OF QUALIFIERS FOR THE EVALUATION AND MANAGEMENT PROCEDURE CODES, SEE (e) OF THIS SUBCHAPTER.
Code Narrative
10040 Acne surgery (e.g. marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) QUALIFIER: This code is limited to severe acne; for less severe acne, utilize procedure codes for routine office visit. Excision must involve the use of a scalpel and an expresser but not an expresser alone.
11975 Insertion, implantable contraceptive capsules. QUALIFIER: The maximum fee allowance is reimbursed for the insertion or reinsertion of the "Norplant System" (six levonorgestrel implants) and the post insertion visit when provided in a hospital setting, when the physician bills for the service. When using this procedure code, the physician will not be reimbursed for the cost of the kit. The supplier of the kit to the physician will be reimbursed directly for the cost of the kit.
11975 22 Insertion, implantable contraceptive capsules. QUALIFIER: The maximum fee allowance is reimbursed includes the cost of the kit supplied to the physician, the insertion of the "Norplant System" (six levonorgestrel implants) and the post insertion visit. NOTE: The "22" modifier indicates the inclusion of the cost of the kit.
11976 Removal of implantable contraceptive capsules. QUALIFIER: The maximum fee allowance is reimbursed for the removal of the "Norplant System" (six levonorgestrel implants) and for the post removal visit.
11977 Removal of implantable contraceptive capsules. QUALIFIER: The maximum fee allowance is reimbursed for the removal of the "Norplant System" (six levonorgestrel implants).
11977 22 Removal with reinsertion, implantable contraceptive capsules. QUALIFIER: The maximum fee allowance is reimbursed for the removal and reinsertion of the "Norplant System" (six levonorgestrel implants) and for the post removal/reinsertion visit. NOTE: Modifier "22" indicates that the billing includes the cost of the NPS kit.
36510 Catheterization of umbilical vein for diagnosis or therapy; newborn. QUALIFIER: May be used in addition to a Hospital Inpatient Services or Inpatient Consultation procedure codes, if applicable, but not in addition to Critical Care or Prolonged Detention procedure codes.
36660 Catheterization of umbilical artery, newborn, for diagnosis or therapy. QUALIFIER: May be used in addition to a Hospital Inpatient Services or Inpatient Consultation procedure codes, if applicable, but not in addition to Critical Care or Prolonged Detention procedure codes.
(b) Diagnostic endoscopy: The following are the qualifiers for HCPCS procedure codes for diagnostic endoscopic procedure codes.
1. Respiratory System (CPT codes 30000-32999)
31520 Laryngoscopy direct, with or without tracheoscopy; diagnostic newborn. QUALIFIER: When combined with another endoscopic procedure, each procedure may be reimbursed at 100% of the maximum fee allowance.
31525 Laryngoscopy direct, with or without tracheoscopy; diagnostic except newborn. QUALIFIER: When combined with another endoscopic procedure, each procedure may be reimbursed at 100% of the maximum fee allowance.
31575 Laryngoscopy, flexible fiberoptic; diagnostic QUALIFIER: When combined with another endoscopic procedure, each procedure may be reimbursed at 100% of the maximum fee allowance.
31615 Tracheobronchoscopy through established tracheostomy incision. QUALIFIER: When combined with another endoscopic procedure, the procedure may be reimbursed at the rate of the maximum fee allowance of the procedure of the "deepest penetration".
31622 Diagnostic (flexible or rigid) with or without all washing or brushing. QUALIFIER: When combined with another endoscopic procedure, the procedure may be reimbursed at the rate of the maximum fee allowance of the procedure of the "deepest penetration"
2. Hemic and Lymphatic systems (CPT codes 38100-39599)
39400 22 Mediastinoscopy with biopsy QUALIFIER: Multiple surgery pricing applies.
3. Digestive system (CPT codes 40490-49999)
i. Upper gastrointestinal system
43200 Esophagoscope, rigid or flexible; diagnostic, with or without removal of foreign body QUALIFIER: When combined with another endoscopic procedure, the procedure may be reimbursed at the rate of the maximum fee allowance of the procedure of the "deepest penetration".
43234 Upper gastrointestinal endoscopy simple primary examination (e.g. with small diameter flexibile fiberscope) QUALIFIER: When combined with another endoscopic procedure, the procedure may be reimbursed at the rate of the maximum fee allowance of the procedure of the "deepest penetration".
43235 Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum, as appropriate; complex diagnostic QUALIFIER: When combined with another endoscopic procedure, the procedure may be reimbursed at the rate of the maximum fee allowance of the procedure of the "deepest penetration".
ii. Lower gastrointestinal
45300 Proctosigmoidoscopy; diagnostic (separate procedure) QUALIFIER: When combined with another endoscopic procedure, the procedure may be reimbursed at the rate of the maximum fee allowance of the procedure of the "deepest penetration".
45330 Sigmoidoscopy, flexible fiberoptic; diagnostic QUALIFIER: When combined with another endoscopic procedure, the procedure may be reimbursed at the rate of the maximum fee allowance of the procedure of the "deepest penetration".
46600 Anoscope: diagnostic (separate procedure) QUALIFIER: This diagnostic endoscopy procedure has the least penetration: (despite the "high" HCPCS number). When combined with another endoscopic procedure in the same body system, the reimbursement is at the rate of the maximum fee allowance of any other procedure code that denotes the "deepest penetration".
iii. Biliary tract;
47550 Biliary endoscopy, intraoperative (kaleidoscope) QUALIFIER. When combined with another endoscopic procedure, each procedure may be reimbursed at 100% of the maximum fee allowance.
47552 Biliary endoscopy, intraoperative (kaleidoscope) QUALIFIER: When combined with another endoscopic procedure, each procedure may be reimbursed at 100% of the maximum fee allowance.
iv. Urinary system (CPT codes 50010-53899)
50951 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service QUALIFIER: When combined with another endoscopic procedure, each procedure may be reimbursed at 100% of the maximum fee allowance.
50970 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service QUALIFIER: When combined with another endoscopic procedure, each procedure may be reimbursed at 100% of the maximum fee allowance.
52000 Cystourethroscopy (separate procedure) QUALIFIER: When combined with another endoscopic procedure, each procedure may be reimbursed at 100% of the maximum fee allowance.
v. Female genital system (CPT codes 56000-58999)
57452 Colposcopy (vaginoscopy); (separate procedure) QUALIFIER: When combined with another endoscopic procedure, each procedure may be reimbursed at 100% of the maximum fee allowance.
(c) HCPCS Code Qualifiers
41872 Gingivoplasty QUALIFIER: Reimbursement is based upon a dollar amount for each quadrant.
50590 Lithotripsy, extracorporeal shock wave (Professional Component) (PC) QUALIFIER: For the Professional Component of lithotripsy, extracorporeal shock wave (ESWL), reimbursement includes all professional services (Professional Component pertaining to ESWL performed by the treating physician during this hospitalization, consortium visit or office visit. This code excludes reimbursement of the Technical Component of the ESWL service.
55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) QUALIFIER: As a primary sterilization (family planning procedure), a completed consent form must be attached to the 1500 N.J. claim form. See N.J.A.C. 10:54-5.16
for regulations on sterilizations and hysterectomy.
55450 Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) QUALIFIER: As a primary sterilization (family planning procedure), a completed consent form must be attached to the 1500 N.J. claim form. See N.J.A.C. 10:54-5.16
for regulations on sterilization and hysterectomy.
58301 WM Removal of intrauterine device by certified nurse midwife.
58611 Ligation or transection of fallopian tube(s) when done at the time of obstetrical delivery (caesarean section) or intraabdominal surgery (not a separate procedure) QUALIFIER: This procedure code may be billed separately in addition to the appropriate procedure codes for primary obstetrical or abdominal surgery procedure. This also includes those obstetrical procedure codes used by HealthStart identified providers.
59510 Caesarean delivery only including postpartum care 59514 QUALIFIER: For anesthesia during Caesarean Section, 59515 use Anesthesia reimbursement methodology including the AA modifier and indicating the standard anesthesia formula (time in units of 15 minute intervals) when used in combination with HCPCS 62278 or 62279.
62278 Injection of anesthesia substance (including narcotics), diagnostic or therapeutic; epidural, lumbar or caudal, single QUALIFIER: Only for use during labor or intractable pain. (including insertion of catheter or cannula — lumbar or caudal — single, regardless of time).
62279 Injection of anesthesia substance (including narcotics), diagnostic or therapeutic; epidural, lumbar or caudal, continuous QUALIFIER: Only for use during labor or intractable pain. (including insertion of catheter or cannula — lumbar or caudal — continuously, regardless of time). Reimbursement is at a flat fee unless C-Section is necessary; then, separate reimbursement for the C-Section and anesthesia using the anesthesia reimbursement formula is allowed. This procedure code may be used with HCPCS 59515.
66170 Fistula of sclera for glaucoma: trephination with iridectomy; trabeculectomy QUALIFIER: This procedure code may be billed with the following other procedure codes representing other optical procedure (HCPCS 65850, 66030, 66625, and 67500) and be reimbursed according to the multiple surgical policy.
66920 Discission of secondary membranous cataract QUALIFIER: This procedure code must not be billed with any other procedure code representing any other optical procedure.
66930 Removal of secondary membranous cataract QUALIFIER: This procedure code must not be billed with any other procedure code representing any other optical procedure.
66940 Removal of lens material; aspiration techniques, one or more stages. QUALIFIER: This procedure code must not be billed with any other procedure code representing any other optical procedure.
67221 Photodynamic therapy QUALIFIER: This procedure code may be billed with 67225. This procedure code must be rendered by ophthalmologists who are retinal specialists, and shall be limited to patients meeting the following criteria: Best corrected visual acuity equal to or better than 20/200 it the decreased visual acuity is caused by the macular degeneration: and Classic subfoveal choroidal neovascularization (CNV), occupying 50 percent or greater of the entire ocular lesion; and A reported ICD-9 CM diagnosis of 115.02, 115.92, 362.21 or 362.52 (exudative senile macular degeneration) NOTE: Report HCPCS procedure code 67225 on the CMS 1500 claim form for procedures performed on a second eye when both eyes are treated on the same date of service. Evaluation and management (EM) services, fluorescent angiography (FA) and other ocular diagnostic services may also be billed separately when determined medically necessary and provided on the same date of service. Modifiers LT or RT should be used on all claims for codes 67221 and 67225, whether initial or subsequent treatment
67225 Photodynamic therapy, second eye, at single session QUALIFIER: This procedure code must be billed with 67221. This procedure code must be rendered by ophthalmologists who are retinal specialists, and shall be limited to patients meeting the following criteria: Best corrected visual acuity equal to or better than 20/200 if the decreased visual acuity is caused by the macular degeneration; and Classic subfoveal choroidal neovascularization (CNV), occupying 50 percent or greater of the entire ocular lesion; and A reported ICD-9 CM diagnosis of 115.02, 115.92, 362.21 or 362.52 (exudative senile macular degeneration). NOTE: Report HCPCS procedure code 67225 on the CMS 1500 claim form for procedures performed on a second eye when both eyes are treated on the same date of service. Evaluation and management (EM) services, fluorescent angiography (FA) and other ocular diagnostic services may also be billed separately when determined medically necessary and provided on the same date of service. Modifiers LT or RT should be used on all claims for codes 67221 and 67225, whether initial or subsequent treatment.
69930 Cochlear device implantation, with or without mastoidectomy QUALIFIER: Reimbursement limited to those cases that meet the current Medicare Selection Criteria.
70470 52 Limited computerized axial tomography, head or body 70482 52 for medical necessary follow-up or monitoring 70488 52 QUALIFIER: For C.A.T. scan guidance (monitoring) 70492 52 performed in conjunction with biopsy, aspiration, 71270 52 puncture, injection of contrast material, placement of 74170 52 tube stint, drain, etc. use codes with modifier "52".
(d) Magnetic Resonance Imaging (MRI) Diagnostic Services:
QUALIFIER: An MRI service provided by physicians in an office setting may be billed to and reimbursed by Medicaid only when the recipient is other than a hospital inpatient. The Medicaid Maximum Fee Allowance is the composite rate and shall not be split between the technical component and the professional component. These rules apply to the billing of the HCPCS for MRI as follows:
70540 72148 70551 72156 70552 72157 70553 72158 71550 72196 72141 72220 72142 73720 72146 73721 72147 74181
72170 Radiologic examination, pelvis; anteroposterior only QUALIFIER: Pelvis x-ray is not eligible for separate payment when performed in conjunction with complete lumbarsacral spine x-rays (72100, 72110, 72114, 72120)
76805 Echography, pregnant uterus, B-scan and/or real time with image documentation; complete (complete fetal and maternal evaluation) QUALIFIER: Limited to one complete study per pregnancy per provider. Any additional medically necessary studies performed by the same provider will be reimbursed as HCPCS 76815 (limited study). Also, only one study (complete or limited or follow-up) can be reimbursed to the same provider on a given day.
76815 Echography, pregnant uterus, B-scan and/or real time with image documentation; limited (gestational age, heart beat, placental location, fetal position, or emergency in the delivery room.) QUALIFIER: Subsequent to the third study, a statement of medical necessity attesting that the pregnancy is high risk with substantiating reasons is required to be attached to the claim. Only one study (complete or limited or follow-up) can be reimbursed to the same provider on a given day.
76816 Echography, pregnant uterus, B-scan and/or real time with image documentation; follow-up or repeat QUALIFIER: Subsequent to the third study, a statement of medical necessity attesting that the pregnancy is high risk with substantiating reasons is required to be attached to the claim. Only one study (complete or limited or follow-up) can be reimbursed to the same provider on a given day.
77790 Supervision, handling and loading radioelement QUALIFIER: Reimbursable only when performed by a Radiologist
78805 Radionuclide localization of abscess: limited area QUALIFIER: Reimbursable only when performed by a Radiologist.
*** FOR QUALIFIERS FOR PATHOLOGY AND LABORATORY SERVICES PROCEDURE CODES. SEE THE SECTION OF THIS SUBCHAPTER AT N.J.A.C. 10:54-9.9.
**** FOR QUALIFIERS FOR PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW (PASARR), SEE THE SECTION OF THIS SUBCHAPTER AT N.J.A.C. 10:54-9.10.
90741 Immunization, passive; Immune serum globulin, human (ISG) QUALIFIER: Prior authorization from the Medical Consultant at the Medicaid District Office is required.
90742 Immunization, passive; Specific hyperimmune serum globulin, human (ISG); e.g. hepatitis B, measles, pertussis, rabies, Rho(D), tetanus, vaccinia, varicella zoster QUALIFIER: Prior authorization from the Medical Consultant at the Medicaid District Office is required.
90780 IV infusion therapy, (excluding allergy, immunizations and chemotherapy) administered by physician exclusive of his/her other duties or under direct supervision of physician by a practitioner: up to one hour QUALIFIER: Not to be used for routine IV drug injection or infusion Reimbursement is contingent upon the required medical necessity, hand written chart documentation including time and indication of physician's presence with the patient to the exclusion of his other duties.
90781 IV infusion therapy, (excluding allergy, immunization and chemotherapy) administered by physician exclusive of his or her other duties or under direct supervision of physician; each addition hour after first hour, up to eight hours QUALIFIER: Not to be used for routine IV drug injection or infusion. Reimbursement is contingent upon the required medical necessity, hand written chart documentation including time and indication of physician's presence with the patient to the exclusion of his or her other duties.
90799 Unlisted therapeutic or diagnostic injection (For allergy immunization, see HCPCS 95000 et seq.) QUALIFIER: This procedure code may be used for intradermal, subcutaneous, or intra arterial injections. Reimbursement is on a flat fee basis and are all inclusive for the cost of the service and the materials. (See also N.J.A.C. 10:54 for reimbursement using "J" codes.) Intravenous and intraarterial injections are reimbursable only when performed by the physician.
90801 Initial Comprehensive Psychiatric Evaluation DESCRIPTION: Psychiatric diagnostic interview examination including history, mental status or disposition (may include communication with family or other sources, ordering medical interpretation of laboratory or other medical diagnostic studies. In circumstances other informants will be seen in lieu of the patient.) QUALIFIER: This code requires for reimbursement purposes a minimum of 50 minutes of direct clinical involvement with the patient or family member.
90830 Psychological testing, by physician, with a written report, per hour QUALIFIER: One unit is equal to 1 hour of psychological testing.
90843 Individual Psychotherapy — 20-30 minute session QUALIFIER: This code requires for reimbursement purposes a minimum of 25 minutes of direct personal clinical involvement with the patient or family member.
90844 Individual Psychotherapy — 45-50 minute session QUALIFIER: This code requires for reimbursement purposes a minimum of 50 minutes of direct personal clinical involvement with the patient or family member.
90847 Family Therapy — 50 minute session QUALIFIER: This code requires for reimbursement purposes a minimum of 80 minutes of direct personal clinical involvement with the patient or family member.
90847 22 Family Therapy — 80 minute session QUALIFIER: This code requires for reimbursement purposes a minimum of 80 minutes of direct personal clinical involvement with the patient or family member.
90853 Group medical psychotherapy (other than of a multiple-family group) by a physician, with continuing medical diagnostic evaluation and drug management when indicated QUALIFIER: Psychotherapy Group (maximum 8 persons per group: 90 minutes, per person, per session.)
90887 Family Conference — 25 minute session QUALIFIER: This code requires for reimbursement purposes a minimum of 25 minutes of direct personal clinical involvement with the patient or family member. The CPT narrative otherwise remains applicable.
92568 Acoustic reflex testing QUALIFIER: Must include at least two (2) frequencies per ear.
92977 Thrombolysis, coronary; by intravenous infusion QUALIFIER: Reimbursable only when performed by a physician whose personal involvement would include the exclusion of all other duties and services.
97799 Physical therapy QUALIFIER: This procedure code may be used for the initial evaluation for physical therapy in the home or for physical therapy in a physicians office or independent clinic. Must not be used for continuing physical therapy in the home or in hospital inpatient or outpatient settings.
99082 Unusual travel (e.g. transportation and escort of patient) QUALIFIER: This procedure code may be used for travel costs only associated and billed with HOUSE CALL or HOME VISIT. (See procedure codes 99341, 99341 WM, 99342, 99342 WM, 99343, 99351, 99351 WM, 99352, 99352 WM, 99353.
99190 Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour QUALIFIER: Reimbursable only when personally performed by a physician.
99191 Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); 3/4 hour QUALIFIER: Reimbursable only when personally performed by a physician.
99192 Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring): 1/2 hour QUALIFIER: Reimbursable only when personally performed by a physician.
(e) The following statements and qualifiers apply to the "Evaluation and Management" procedure codes (HCPCS 99201-99499).
OFFICE OR OTHER OUTPATIENT SERVICES — NEW PATIENT; HOSPITAL INPATIENT SERVICES — INITIAL HOSPITAL CARE; NURSING FACILITY SERVICES-COMPREHENSIVE NURSING FACILITY ASSESSMENTS; AND DOMICILIARY, REST HOME, OR CUSTODIAL CARE SERVICES — NEW PATIENT
(Excludes Preventive Health Care for patients through 20 years of age.)
99201 99202 When reference is made in your CPT manual to Office or 99203 Other Outpatient Services — New Patient; Hospital 99204 Inpatient Services — Initial Hospital Care; Nursing 99205 Facility Services — Comprehensive Nursing Facility 99221 Assessments; and Domiciliary, Rest Home, or Custodial 99222 Care Services New Patient; the intent of Medicaid is to 99223 consider this service as the Initial Visit 99301 When the setting for this Initial Visit is an office or 99302 residential health care facility, for reimbursement 99303 purposes it is limited to a single visit. Future use of 99321 this category of codes will be denied when the recipient 99322 is seen by the same physician, group of physicians, or 99323 involves a shared health care facility which is a group of physicians sharing a common record. Reimbursement for an initial office visit also precludes subsequent reimbursement for an initial residential health care facility visit and vice versa. Reimbursement for an initial office visit or initial residential health care facility visit will be disallowed, if a preventive medicine service, EPSDT examination or office consultation were billed within a twelve month period by a physician, group, shared health care facility, or practitioner sharing a common record. If the setting is a nursing facility or hospital, the Initial Visit concept will still apply for reimbursement purposes despite CPT reference to the term Initial Hospital Care or Comprehensive Nursing Facility Assessments. Subsequent readmissions to the same facility may be reimbursed as Initial Visits, if the readmission occurs in more than 30 days from a previous discharge from the same facility by the same provider. In instances when the readmission occurs within 30 or less days from a previous discharge, the provider shall bill the relevant HCPCS procedure codes specified in the qualifier under the headings Subsequent Hospital Care or Subsequent Nursing Facility Care. Initial Hospital Visit during a single admission will be disallowed to the same physician, group, shared health care facility, or practitioners sharing a common record who submit a claim for a consultation and transfer the patient to their service. It is also to be understood that in order to receive reimbursement for an Initial Visit, the following minimal documentation must be on the record regardless of the setting where the examination was performed:
Example:
1. Chief complaint(s);
2. Complete history of the present illness and related systemic review — including recordings of pertinent negative findings;
3. Pertinent past medical history;
4. Pertinent family history:
5. A full physical examination pertaining to but not limited to the history of the present illness and includes recording of pertinent negative findings; and
6. Working diagnoses and treatment plan including ancillary services and drugs ordered.
NOTE: Record and documentation of visits to patients in residential health care facilities should be maintained in the providers' office record.
EXCEPTIONS: HCPCS procedure codes 99201 and 99202 are exceptions to the above requirements outlined in the qualifier for the initial visit. For codes 99201 and 99202, the provider is expected to follow the qualifier applied to routine visit or follow-up care visit for reimbursement purposes.
OFFICE OR OTHER OUTPATIENT SERVICES — ESTABLISHED PATIENT; HOSPITAL INPATIENT SERVICES — SUBSEQUENT HOSPITAL CARE; NURSING FACILITY SERVICES — SUBSEQUENT NURSING FACILITY CARE; AND DOMICILIARY, REST HOME OR CUSTODIAL CARE SERVICES — ESTABLISHED PATIENT
(Excludes Preventive Health Care for patients through 20 years of age.)
99211 When reference is made in your CPT manual to Office or 99211 WM Other Outpatient Services — Established Patient; Hospital 99212 Inpatient Services — Subsequent Hospital Care; Nursing 99212 WM Facility Services — Subsequent Nursing Facility Care; and 99213 Domiciliary, Rest Home or Custodial Care Services — 99213 WM Established Patient: the intent of Medicaid is to consider 99214 this service as the Routine Visit or Follow-up Care visit. 99214 WM The setting could be office, hospital, nursing facility or 99215 residential health care facility. 99215 WM In order to document the record for reimbursement 99231 purposes, a progress note for the noted visits should 99232 include the following: 99233 1. In an office, or residential health care facility. 99311 (a) Purpose of visit; 99312 (b) Pertinent history obtained; 99313 (c) Pertinent physical findings including pertinent 99331 negative findings based on the above; 99332 (e) Lab. X-ray, EKG, etc., ordered with results; 99333 and (f) Diagnosis. 2. In a hospital or nursing facility setting. (a) Update of symptoms; (b) Update of physical findings; (e) Resume of findings of procedures, if any done; (d) Pertinent positive and negative findings of lab. X-ray: (e) Additional planned studies, if any, and why; and (f) Treatment changes, if any.
HOME SERVICES AND HOUSE CALLS
99343 House Call 99353 The "House Call" code does not distinguish between specialist and non-specialist. These codes do not apply to residential health care facility or nursing facility setting. These codes refer to a physician visit limited to the provision of medical care to an individual who would be too ill to go to a physician's office and/or is "home bound" due to his/her physical condition. When billing for a second or subsequent patient treated during the same visit, the visit should be billed as a home visit. 99341 Home Visit 99341 WM For purposes of Medicaid reimbursement, these codes 99342 apply when the provider visits Medicaid recipients in 99342 WM the home setting and the visit does not meet the 99351 criteria specified House Call listed above. 99351 WM 99352 99352 WM
The record and documentation of a Home Visit or House Call shall become part of the office progress notes and shall include, as appropriate, the following information:
1. Purpose of visit;
2. Pertinent history obtained;
3. Pertinent physical findings, including pertinent negative physical findings based on 1. and 2.;
4. Procedures, if any performed, with results;
5. Lab, X-ray, ECG, etc, ordered with results; and
6. Diagnosis(es) plus treatment plan status relative to present or pre-existing illness(es) plus pertinent recommendations and actions.
CONSULTATIONS
A consultation is recognized for reimbursement only when performed by a specialist recognized as such by this Program and the request has been made by or through the patient's attending physician and the need for such a request would be consistent with good medical practice. Two types of consultation are recognized for reimbursement — comprehensive consultation and limited consultation.
COMPREHENSIVE CONSULTATION
99244 In order to receive reimbursement for HCPCS codes 99245 99244, 99245, 99254, 99255, 99274 and 99275, the 99254 performance of a total systems evaluation by history and 99255 physical examination, including a total systems review 99274 and total system physical examination, are required. An 99275 alternative to that would be the utilization of one or more hours of the consulting physician's personal time in the performance of the consultation. Reimbursement for HCPCS codes 99244, 99245, 99254, 99255, 99274 and 99275 (Comprehensive Consultation) requires the following applicable statements, or language essentially similar to those statements, to be inserted in the "remarks section" of the claim form. The form is to be signed by the provider who performed the consultation.
Examples:
1. I personally performed a total (all) systems evaluation by history and physical examination, or
2. This consultation utilized 60 or more minutes of my personal time.
The following rules regarding consultations should also be recognized:
1. If a consultation is performed in an inpatient or outpatient setting and the patient is then transferred to the consultant's service during that course of illness, then the provider may not bill for an Initial Visit if he/she bills for the consultation.
2. If there is no referring physician, then an Initial Visit code should be used instead of a consultation code.
3. If the patient is seen for the same illness on repeated visits by the same consultant, then these visits are considered as routine visits or follow-up care visits and not consultations.
4. Consultation codes will be declined in an office or residential health care facility if the consultation has been requested by or between members of the same group, shared health care facility or physicians sharing common records. A routine visit code is applicable under these circumstances.
5. If a prior claim for comprehensive consultation visit has been made within the preceding 12 months, then a repeat claim for this code will be denied if made by the same physician, physician group, shared health care facility or physicians using a common record except in those instances where the consultation required the utilization of one hour or more of the physician's personal time. Otherwise, applicable codes would be limited consultation code if their criteria are met.
LIMITED CONSULTATION
99241 The area being covered for reimbursement purposes is 99242 "limited in the sense that it requires less than the 99243 requirements designated as "comprehensive" as noted 99251 above (Comprehensive Consultation). 99252 99253 99271 99272 99273
SECOND OPINION PROGRAM CONSULTATION
99274YY A consultation to satisfy the requirements of the mandated "Second Opinion" program will be reimbursed only if the requirements of that program are met and the consultation has been performed by the appropriate Board Certified Specialist who has signed a separate provider agreement and whose selection has been through the Second Opinion Referral Service. The appropriate HCPCS code is 99274YY. Reference should be made to Appendix D of the Surgery Section (4.3) of this Subchapter for more detail concerning the program "Second Opinion Referral Service". Also, providers may contact the Second Opinion Referral Service directly at the following toll free number 1-800-676-6562. An indicator "S" will be found in the "IND" column of the HCPCS code listing in the Surgery Section to indicate that procedure requires a Second Opinion Program Consultation.
THIRD OPINION CONSULTATION
99274ZZ In the event that a patient receives two different points of view relative to a "Second Opinion" procedure, he/she may, if unable to reach a decision, request a Third Opinion. The CPT Procedure Code is 99274ZZ. Note: A Third Opinion consultation must be at the patient's request and under the circumstances described.
EMERGENCY DEPARTMENT SERVICES
A. Physician's Use of Emergency Room Instead of Office:
99211 When a physician sees his/her patient in the emergency 99212 room instead of his/her office, the physician must use 99213 the same codes for the visit that would have been used 99214 if seen in the physician's office (99211, 99212, 99213, 99215 99214 or 99215 only). Records of that visit should become part of the notes in the office chart.
B. Hospital-Based Emergency Room Physicians:
99281 When patients are seen by hospital-based emergency 99282 room physicians who are eligible to bill the Medicaid 99283 program, the appropriate HCPCS code is used. The 99284 "Visit" codes are limited to 99281, 99282, 99283, 99285 99284 and 99285.
CRITICAL CARE SERVICES
99291 Critical care will be covered under the code 99291 and 99292 99292, but the service must be consistent with the following narrative in order to be reimbursed. The patient's situation requires constant physician attendance which is given by the physician to the exclusion of his/her other patients and duties and, therefore, for him/her, represents what is beyond the usual service. This must be verified by the applicable records as defined by the setting and which records must show in the physician's handwriting the time of onset and time of completion of the service. All settings are applicable such as office, hospital, home, residential health care facility and nursing facility. Note: These codes may not be used simultaneously with procedure codes that pay a reimbursement for the same time or type of service.
PREVENTIVE MEDICINE SERVICES — ANNUAL HEALTH MAINTENANCE EXAMINATION
New Patient Established Patient
99382 99392 99383 99393 99384 99394 99385 99395 99386 99396 99387 99397
For individuals under 21 years of age, the following must be performed and documented in the recipient's record:
1. History (complete initial for new patient, interval for established patient) including past medical history, family history, social history, and systemic review.
2. Developmental and nutritional assessment.
3. Complete, unclothed, physical examination to include also the following:
(a) measurements: height and weight; head circumference to 25 months; blood pressure for children age 3 or older.
(b) vision and hearing screening.
4. Assessment and administration of immunizations appropriate for age and need.
5. Provisions for further diagnosis, treatment and follow-up, by referral if necessary, of all correctable abnormalities uncovered or suspected.
6. Referral to a dentist for children age 3 or older.
7. Laboratory procedures performed or referred if medically necessary. Recommendations are:
(a) Hemoglobin/Hematocrit three times: 6-8 months; 2-3 or 4-6 years; and 10-12 years.
(b) Urinalysis a minimum of twice: 18-24 months and 13-15 years.
(c) Tuberculin test (Mantoux): 9-12 months; and annually thereafter.
(d) Lead screening using blood lead level determinations between 6 and 12 months, at 2 years of age, and annually up to 6 years of age. At all other visits, screening shall consist of verbal risk assessment and blood lead level test, as indicated.
(e) Other appropriate screening procedures, if medically necessary (for example: blood cholesterol, test for ova and parasites, STD).
8. Health education and anticipatory guidance.
9. Offer of social service assistance; and, if requested, referral to County Welfare Agency.
10. Referral for further diagnosis and treatment or follow-up of all correctable abnormalities, uncovered or suspected. Referral may be made to the provider conducting the screening examination or to another provider, as appropriate.
11. Referral to the Special Supplemental Food program for Women's Infants and Children (WIC) is required for children under 5 years of age and for pregnant or lactating women.
Note: Preventive medicine services codes (new patient) 99382, 99383, 99384, 99385, 99386, and 99387 are comparable to an initial visit and, therefore, may only be billed once. Future use of these codes will be denied when the recipient is seen by the same physician, group of physicians, or involves a shared health care facility, group of physicians sharing a common record. These codes will also be automatically denied for payment when used following an EPSDT examination (procedure code W9820) performed within the preceding 12 months.
Preventive medicine services codes (established patient) 99392, 99393, 99394, 99395, 99396 and 99397 may be used only once in a 12-month period for any individual over 2 years of age. For well-child care provided to children under the age of two, it is suggested that the provider bill for an EPSDT examination.
Preventive medicine services code 99391 and 99392 may be used up to 5 times during the patient's first year of life and up to 3 times during the patient's second year of life respectively, in accordance with the periodicity schedule of preventive visits recommended by the American Academy of Pediatrics. These codes do not apply to children under 2 years of age participating in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) or Pediatric HealthStart program EPSDT and the Pediatric HealthStart providers bill for these services using the program appropriate codes W9060-W9068 or W9060WT-9068WT.
NEWBORN CARE
ROUTINE HOSPITAL NEWBORN CARE — "WELL" BABY
99431 Routine Hospital Newborn Care. For reimbursement purposes, code 99431 requires as a minimum routine newborn care by a physician other than the physician(s) rendering maternity service, including complete initial and complete discharge physical examination, conference(s) with the patient(s). This must be documented in the newborn's medical record. This applies to health newborns. Consequently, the provider is not permitted to bill subsequent day or discharge for a health newborn.
NEWBORN CARE — "SICK" BABY
For sick babies use appropriate hospital care code:
99221 1. Initial hospital care-99221, 99222 or 99223. 99222 99223 99231 2. Subsequent hospital care-99231, 99232 or 99233. 99232 99233 99291 3. Critical care services if applicable-99291 or 99292 99292.
(f) The following statements apply to HCPCS procedure codes which require medical justification.
1. The following is a list of the procedure codes for certain surgical and diagnostic procedures which are reimbursable only when acceptable written justification by the physician accompanies the claim form. The medical justification must include an explanation of the medical justification of the procedure, as appropriate and in accordance with established clinical protocols, and appropriate licensing statute and regulations by the appropriate Board.
2. The medical necessity may be stated in the "REMARKS" box 34 of the 1500 N.J. claim form. If Box 34 does not provide sufficient space, an addendum may be attached to the claim form. (See also N.J.A.C. 10:54-3.2 for regulations regarding this program.) The indicator "M" precedes the procedure codes which require medical justification.
3. LIST OF HCPCS PROCEDURE CODES REQUIRING MEDICAL JUSTIFICATION
64804 71020 64804 50 71030 64818 71034 64818 50 74710 71010 75710
(g) Cosmetic surgery: The following are a list of procedure codes that are considered by Medicaid as cosmetic surgical procedures and unless prior authorized as a result of being considered medically necessary, are not reimbursed.
New Patient Established Patient
15780 15819 30400 69300 15781 15820 30410 69300 50 15782 15821 30420 15783 15822 19325 50 30430 15786 15823 19325 30435 15787 15824 30450 15788 15826 21120 30460 15789 15831 through 30462 15792 21198 30520 15793
(h) Physician Administered Drugs
1. The New Jersey Division of Medical Assistance and Health Services provides physician reimbursement for the administration of medications. Reimbursement will continue to be available for the administration of the drug. The procedure code 90799 may be billed for intradermal, subcutaneous, intramuscular, or intravenous drug administration.
2. However, reimbursement for the drug administered by a physician, other than immunizations, was only available if a prescription was issued and the drug was obtained from a pharmacy which directly billed the New Jersey Medicaid program.
3. Unless otherwise indicated, the Medicaid maximum fee allowance shall be based on the AWP per unit which equals one cubic centimeter (CC) or milliliter (ml). For drug vials with a volume equal to one cc or ml, the Medicaid maximum fee allowance shall be based on the cost per vial. For further information on physician administered drugs, see N.J.A.C. 10:54-8.6.
HCPCS Maximum FeeCode Description Allowance
J0690 Cefazolin 500 mg $ 1.92
J0696 Ceftriaxone 250 mg 10.24
J1100 Dexamethasone 4 mg 0.80
J1200 Diphenhydramine 50 mg 0.55
J2550 Promethazine 50 mg 0.42
J2680 Fluphenazine Decanoate 25 mg 9.50
J2790 RhoGAM, Rho (D) Immune Globulin (Human) Single dose (Micro-Dose) 20.40
J2790 22 RhoGAM, Rho (D) Immune Globulin (Human) Single dose (Full dose) (22 — Services greater than usual) 72.07
J9000 Doxorubicin 10 mg 42.00
J9010 Doxorubicin 50 mg 195.50
J9020 Asparaginase 10,000 Units 50.36
J9031 BCG Live Vaccine 27 mg 152.13
J9040 Bleomycin Sulfate 15 units 255.08
J9045 Carboplatin 50 mg 72.01
J9060 Cisplatin Powder or Solution 10 mg 30.33
J9070 Cyclophosphamide 100 mg 4.91
J9100 Cytarabine 100 mg 6.72
J9130 Decarbazine 100 mg 12.00
J9190 Fluorouracil 50 mg 0.18
J9217 Lupron 7.5 mg 451.25
J9230 Mechlorethamine HCl 10 mg 10.10
J9240 Medroxyprogesterone 100 mg 9.05
J9240 22 Medroxyprogesterone 400 mg 31.50
J9260 Methotrexate Sodium 50 mg 4.75
J9280 Mitomycin 5 mg 119.08
J9360 Vinblastine Sulfate 1 mg 3.25
J9370 Vincristine 1 mg 27.50
W9095 Immunization — Tetanus antitoxin 6.60
(i) Hepatitis B Vaccine: Coverage is available for post exposure prophylaxis and for vaccination of individuals in selected high risk groups, regardless of age, in accordance with the criteria defined by the CDC. In all such cases, the need for this vaccination must be fully documented in the recipient's medical record. In order to facilitate reimbursement for Hepatitis B immunoprophylaxis for high risk individuals, manufacturer, age, and dose specific procedure codes have been developed for use by physicians and independent clinics providing this service.
EXCEPTION: The New Jersey Medicaid program will reimburse for the universal vaccination of infants born on and after January 1, 1992, whose immunization was delayed beyond the newborn period because this policy was not yet in effect. However, the immunization schedule must be completed before the infant's second birthday.
W9096 Hepatitis B immunoprophylaxis with Recombivax 1 HB, 0.25 ml dose. This code applies only to newborns of HBsAg negative mothers. 17.46
W9096 22 Hepatitis B immunoprophylaxis with Recombivax HB, 0.5 ml dose. This code applies only to newborns of HBsAg positive mothers. 32.79
W9097 Hepatitis B immunoprophylaxis with Recombivax HB, 0.25 ml dose. This code applies only to high risk recipients under 11 years of age (exclusive of newborns). 17.46
W9098 Hepatitis B immunoprophylaxis with Recombivax HB, 0.5 ml dose. This code applies only to high risk recipients 11-19 years of age. 32.79
W9099 Hepatitis B immunoprophylaxis with Recombivax HB, 1.0 ml dose. This code applies only to high risk recipients over 19 years of age. 63.57
W9333 Hepatitis B immunoprophylaxis with Engerix-B, 0.5 ml dose. This code applies only when immunizing newborns. 27.88
W9334 Hepatitis B immunoprophylaxis with Engerix-B, 0.5 ml dose. This code applies only to high risk recipients under 11 years of age (exclusive of newborns) 27.88
W9335 Hepatitis B immunoprophylaxis with Engerix-B, 1.0 ml dose. This code applies only to high risk recipients over 11 years of age. 62.09
W9336 Medroxyprogesterone Acetate 150 mg 36.90
W9337 Cephradine 250 mg 2.34
W9338 TETRAMUNE, a biological combining Diphtheria, Tetanus Toxoids and Pertussis Vaccine (DTP) with Hemophilus B Conjugate Vaccine 30.27 QUALIFIER: Not to be billed separately with HCPCS 90701 or 90731.
W9339 Lupron 3.75 mg 360.63
W9343 Lupron Depot Pediatric 7.5 mg 451.25
W9344 Lupron Depot Pediatric 11.25 mg 811.25
W9345 Lupron Depot Pediatric 15 mg 902.50
Amended by R. 2006 d. 26, effective February 6, 2006. See: 37 N.R.J. 3538(a), 38 N.R.J. 966(a). In (c), corrected the placement of HCPCS code 66170 and added the qualifiers for the new HCPCS procedure codes 67221 and 67225. Amended by R. 2007 d. 188, effective June 18, 2007. See: 39 N.R.J. 337(a), 39 N.R.J. 2360(a). In the table in (d), in the first Qualifier paragraph, deleted "only" following "may", inserted "only" following "reimbursed by Medicaid" and substituted "shall" for "must"; and in the Qualifier paragraph of the entry for 90801, deleted the final sentence.