N.J. Admin. Code § 10:54-4.13

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

Section 10:54-4.13 - HCPCS codes for surgical procedures; general

(a) The New Jersey Medicaid/NJ FamilyCare program shall reimburse for surgical services based on a surgical package concept, which includes the following components:

1. Pre-operative care, which shall include any consultations and/or evaluations performed within 48 hours prior to surgery by the surgeon performing the surgery and routine visits (office or hospital) on the day of surgery, except that:

i. Initial hospital visits may be reimbursed on the day of surgery, unless the surgery involves certain obstetrical delivery codes (see 10:54-9.10 for a listing of these delivery codes); and

ii. When the patient is undergoing same day surgery (hospital outpatient) or surgery in an ambulatory surgical center (independent clinic), the pre-surgical history, physical examination, and risk evaluation provided on the same day may be billed by the physician. (See also 10:54-9.4.)

2. The performance of the operation (surgical procedure) itself;

3. Anesthesia services, when rendered by the operating surgeon (that is, local anesthesia or nerve blocks); and

4. Normal post-operative care.

i. A listing of surgical codes, with corresponding follow-up days, is provided in 10:54-9.4. During the corresponding follow-up days, normal follow-up post-operative care (that is, office visits) shall not be billed separately from the all inclusive operative fee. No additional reimbursement shall be made to the provider for routine care during the follow-up period.

N.J. Admin. Code § 10:54-4.13

Recodified from N.J.A.C. 10:54-4.12 by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Former N.J.A.C. 10:54-4.13, Pre-surgery consultation and evaluation, recodified to N.J.A.C. 10:54-4.14.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In the introductory paragraph of (a), inserted "/NJ FamilyCare".