N.J. Admin. Code § 10:54-4.15

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

Section 10:54-4.15 - Simultaneous visit and other procedures

(a) If the physician bills for an office/outpatient visit at the time of the surgical procedure, reimbursement may be made for either the surgical procedure, at 100 percent of the Medicaid/NJ FamilyCare maximum fee allowance, or for the office/hospital outpatient visit.

(b) The following situations are exceptions to (a) above:

1. Venipuncture (HCPCS 36415) may be billed once per patient visit in addition to an office/hospital outpatient visit when the visit fulfills requirements of a visit and the sample is sent to an outside laboratory for processing;

2. Aspiration or injection into joints (HCPCS 20600-20610) may be billed with an office/hospital outpatient visit;

3. Medication injected into tendon sheaths, ligament trigger points or ganglion cysts (HCPCS 20550) may be billed with an office/hospital outpatient visit; and

4. Procedure codes listed in 10:54-9.4.

(c) In order to be properly reimbursed for the surgical procedure, the physician shall bill for the surgical procedure, rather than for the office or outpatient visit, in those instances where the surgical procedure fee exceeds the office or outpatient visit.

N.J. Admin. Code § 10:54-4.15

Recodified from N.J.A.C. 10:54-4.14 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. 10:54-4.15, Multiple surgical procedures; same session, recodified to N.J.A.C. 10:54-4.16.
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 (a), inserted "/NJ FamilyCare".