N.J. Admin. Code § 10:54-2.2

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10:54-2.2 - Direction of physician or other permitted and qualified health care professional services

(a) Personal direction of physicians or other permitted and qualified health care professionals means that the services listed in this section shall be rendered in the participating physician's physical presence during part or all of the procedure or service, as specified in this section. It is not the intent of the program to reimburse a participating physician for medical care, and/or history and/or physical examinations performed by residents or other permitted and qualified health care professionals, without the participating physician's physical presence.

1. The Medicaid/NJ FamilyCare participating physician who bills the program for his or her service shall be physically present and shall perform or personally direct the key portion of the service billed, as follows:

i. If the participating physician cannot identify a key portion of the service, then he or she shall be present for the entire service.

2. It shall be the participating physician's decision whether he or she should perform hands-on care, in addition to the care furnished by the resident in his or her presence.

3. The participating physician shall personally document in the medical record(s) his or her participation in the service. A countersignature alone shall not be sufficient.

4. The combined notes of the participating physician and the resident or other permitted and qualified health care professional shall be adequate to substantiate the level of service required by the patient and billed to the program.

5. The services that shall be rendered within the participating physician's physical presence shall include the following:

i. Evaluation and management (E/M) services, including critical care;

ii. Renal dialysis services;

iii. Anesthesia services;

iv. Surgery, high-risk, or other complex procedures;

v. Interpretation of diagnostic radiology and other diagnostic tests; and

vi. Psychiatric services.

6. An exception to the participating physician's physical presence requirement shall be granted for certain evaluation and management codes of lower and mid-level complexity if all of the following criteria are met:

i. Services are furnished at the outpatient department of a hospital or another licensed ambulatory care facility, and not at a physician's office or a patient's residence;

ii. Any resident furnishing the service without the presence of a participating physician shall have completed more than six months of a State-approved residency program, as documented by the health care entity providing the service; and

iii. The participating physician shall not direct patient care provided by more than four residents at any time, shall be immediately available to the resident and patient when directing such care, and shall:

(1) Have no other responsibilities at the time;

(2) Assume care management responsibility for those beneficiaries seen by the residents;

(3) Ensure that the services furnished are appropriate;

(4) Review with each resident, during or immediately after each visit, the beneficiary's medical history, physical examination, diagnosis, plan of care, and record of tests and therapies; and

(5) Document in the beneficiary's medical record the extent of his or her own participation in the review and direction of the services furnished to each beneficiary.

(b) Evaluation and management (E/M) services shall include:

1. Office visits or other outpatient services for new or established patients;

2. Emergency department services for new or established patients;

3. Hospital inpatient services for new or established patients;

4. Subsequent hospital visits;

5. Comprehensive nursing facility assessments for new or established patients;

6. Subsequent nursing facility care;

7. Domiciliary, rest home, or home visits for new or established patients; and

8. Preventive medicine services for new or established patients.

(c) E/M services in a critical care setting are time-based services which can be billed using the time that the participating physician actually spent on the individual patient's care, as delineated in (a) above. For E/M services, the participating physician shall be at the procedure or service site, with the patient, for the period of time for which the claim is made.

(d) Renal dialysis services shall include end stage renal disease services and dialysis procedures, and shall be provided in accordance with (a) above.

(e) Anesthesia services shall meet the following requirements:

1. The participating physician who bills the program for his or her service shall direct no more than two anesthesia procedures concurrently and shall not perform any other service while he or she is directing the concurrent procedures;

2. The participating physician shall prescribe the anesthesia plan;

3. The participating physician shall personally participate in all critical portions of the procedure or service;

4. The participating physician shall be immediately available to furnish services during the entire service or procedure; and

5. The participating physician shall provide documentation in the anesthesia record that shall indicate the participating physician's presence or participation in the administration of the anesthesia.

(f) Surgery, high-risk, or other complex procedures shall include, but shall not be limited to, cardiac catheterization, transesophageal echocardiography, interventional radiologic and cardiologic supervision and interpretation, and endoscopy. For reimbursement purposes, surgery, high-risk or other complex procedures shall meet the following requirements:

1. The participating physician specializing in the appropriate medical field for the procedure or service performed shall be physically present with the resident during all critical and key portions of the health care service or medical procedure for which payment is sought. If needed, the participating physician shall be immediately available to furnish services during the entire health care service or medical procedure;

2. The medical record shall document that the participating physician was present at the time the service was being furnished. The notes in the medical record(s) made by the physician, resident, and any participating nurse shall all indicate the presence of the participating physician during the procedure(s); and

3. The following requirements shall apply to the procedures specified below:

i. For surgery, the participating physician's presence shall not be required during the opening and closing of the surgical field;

ii. For cardiac catheterization, transesophageal echocardiography, interventional radiologic and cardiologic procedures, or procedures performed through an endoscope, the participating physician shall be present from the insertion of the device until the removal of the device. The viewing of the entire procedure by the participating physician through a monitor in another room shall not meet this requirement; and

iii. For minor procedures, such as a simple suture, the participating physician shall be physically present for the entire procedure.

(g) For interpretation of diagnostic radiology and other diagnostic tests, in order to be eligible for reimbursement, the participating physician need not be physically present during the actual performance of the radiologic studies or other diagnostic tests. The participating physician's documentation shall indicate that he or she personally performed the interpretation or reviewed the resident's interpretation with the resident. A countersignature alone of the resident's interpretation by the teaching or billing physician shall not be an acceptable form of documentation.

(h) For psychiatric services to be eligible for reimbursement, all requirements contained in (a) above shall be met, except that the requirement for the presence of the participating physician during the service in which a resident is involved shall, if not met by physical presence in the treatment room, be met by use of a one-way mirror, video equipment, or similar device to observe the resident-patient interaction during the time the service is furnished.

1. For time-based psychiatric services, the participating physician shall bill only for the length of time he or she was present during the therapy session. For example, if the participating physician only participated in a 15-minute portion of a 30-minute session, only 15 minutes shall be billed, not the entire half-hour.

N.J. Admin. Code § 10:54-2.2

Amended by R.2003 d.97, effective 3/3/2003.
See: 34 New Jersey Register 3462(a), 35 New Jersey Register 1277(b).
Rewrote the section.