N.J. Admin. Code § 10:54-4.30

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

Section 10:54-4.30 - Consultation; use of all consultation codes

(a) Except where medical necessity dictates or where a hospital policy, state law or regulation dictates otherwise, multiple and simultaneous consultations in the same specialty for the same disease, illness or condition, whether in or out of a hospital, shall not be reimbursed.

(b) If there is no referring physician (such as, when the patient either makes an appointment on his own or when care is recommended by another physician who does not request a report of the specialist findings) or there is not an appropriate state agency referral, the appropriate initial office visit procedure code should be utilized rather than the code for consultation.

(c) If a consultation is performed in a nursing facility and the patient is then transferred to the service of the consultant, then the consultant shall bill for one of the consultation procedure codes or a COMPREHENSIVE NURSING FACILITY ASSESSMENTS (NEW or ESTABLISHED) for that visit and reimbursement will be for one, not both of these codes.

(d) If proper documentation is not forthcoming on the medical record, the consultation visit may be denied. One of the following statements shall be included on the medical record to indicate that a comprehensive consultation was performed by the physician.

1. "I personally performed a total (all) systems evaluation by history and physical examination"; or

2. "This consultation utilized one hour or more of my personal time."

(e) When consultative services are performed in the physician's office or the beneficiary home, the name and individual Medicaid/NJ FamilyCare Provider Service Number (MPSN) of the referring physician or the name of the person from the State agency making the referral must be included on the claim form.

(f) When reporting consultative services, the provider shall specify whether the consultation was Limited, Comprehensive or Follow-up Consultation. Limited, Comprehensive and/or Follow-up Consultation shall be denied if performed in an office, a residential health care facility, or home setting, if the consultation has been requested by, between, or among members of the same groups, shared health care facility, or physicians sharing common records. (See 10:54-9.4 for consultation HCPCS codes.)

(g) If a prior claim for comprehensive consultation visit has been made within the preceding 12 months, then a repeat claim for this code shall be denied if made by the same physician, physician group, or shared health care facility 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, the applicable codes shall be the limited consultation codes, if those criteria are met.

(h) In the case of a consultation, the physician is entitled to payment for services provided, subject to the limitations listed in (a) through (g) above. If, after a consultation, a transfer of patient care is made, reimbursement for services shall only be made to the current physician.

(i) A physician may bill for a consultation initiated by an APN, whether the APN is employed as part of a group or whether the APN is employed independently. However, the collaborating physician of the APN shall not bill for consultation services provided to the APN. When it becomes necessary to admit a patient for inpatient hospital care, or to prescribe controlled drugs, the collaborating physician may bill for concurrent care limited to a single visit for each episode.

(j) An APN-initiated consultation with another health care professional, excluding the collaborating physician and another APN, will be allowed under the following conditions:

1. Where a medical condition requires evaluation from more than one perspective, discipline or specialty;

2. Where significant medical necessity exists; and

3. Where, subsequent to the consultation, the primary practitioner will either resume sole responsibility or transfer the patient to the consultant.

N.J. Admin. Code § 10:54-4.30

Recodified from N.J.A.C. 10:54-4.29 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. 10:54-4.30, Concurrent care; physicians, recodified to N.J.A.C. 10:54-4.31.
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.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (e), substituted "beneficiary" for "recipient's" preceding "home".
Amended by R.2004 d.334, effective 9/7/2004.
See: 36 N.J.R. 312(a), 36 N.J.R. 4136(a).
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In (e), inserted "/NJ FamilyCare".