N.J. Admin. Code § 10:54-4.4

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

Section 10:54-4.4 - HCPCS codes for new patients visits

(a) This rule applies to office, and hospital inpatient and outpatient services to new patients (excluding preventive health care for patients through 20 years of age).

(b) When the CPT manual refers to office or hospital inpatient or outpatient services-new patient, the Medicaid/NJ FamilyCare program will consider this service an initial visit.

1. When the setting for an initial visit is an office or residential health care facility, reimbursement shall be limited to a single visit. Future requests for reimbursement which include this category of codes will be denied when the beneficiary is seen by the same physician, practitioner, group of physicians/practitioners, or shared health care facility sharing a common record. Reimbursement for an initial office visit precludes subsequent reimbursement for an initial residential health care facility visit and vice versa.

2. 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 was billed within a twelve month period by a physician, group, shared health care facility, or practitioner sharing a common record.

(c) If the setting is a nursing facility or hospital, the initial visit concept shall still apply when considered for reimbursement purposes despite CPT reference to the terms initial hospital care as applying to a new or established patient. Subsequent readmissions to the same facility may be designated as initial visits (as long as a time interval of 30 days or more has elapsed between admissions).

(d) Reimbursement for an initial hospital visit shall be disallowed to the same physician, practitioner, group of physicians/practitioners, or shared health care facility sharing a common record who submit a claim for a consultation and transfer the patient to their service. "Consultation" and "Initial Hospital Visit" shall not be billed for the same provider on the same patient on the same day of service.

(e) In order to receive reimbursement for an initial visit, the documentation requirements set forth in 10:54-2.6 through 2.12 shall be met, regardless of where the examination was performed.

N.J. Admin. Code § 10:54-4.4

Recodified from N.J.A.C. 10:54-4.3 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. 10:54-4.4, Use of HCPCS codes for establishing patient visits, recodified to N.J.A.C. 10:54-4.5.
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 (b)1, substituted "beneficiary" for "recipient" preceding "is seen by the same physician,".
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 (b), inserted "the" preceding and "/NJ FamilyCare program" following "Medicaid".