N.J. Admin. Code § 10:54-8.4

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

Section 10:54-8.4 - Pharmaceutical; Physician-administered drugs

(a) The New Jersey Medicaid/NJ FamilyCare program shall reimburse physicians for certain approved drugs administered by inhalation, intradermally, subcutaneously, intramuscularly or intravenously in the office, home or independent clinic setting according to the following reimbursement methodologies:

1. Physician-administered medications shall be reimbursed directly to the physician. For this methodology, the physician is required to bill the appropriate "J" code in conjunction with the appropriate HCPCS procedure code as described below.

i. A "J" code may be billed in conjunction with an office, home, or independent clinic visit when the criteria for an office or home visit is met and the procedure code for the method of drug administration. The HCPCS 90799 may be billed for intradermal, subcutaneous, intramuscular, or intravenous drug administration. Other HCPCS procedure codes may be billed for the administration of allergy, chemotherapy or inhalation drugs.

ii. The New Jersey Medicaid/NJ FamilyCare program has assigned HCPCS procedure codes and Medicaid maximum fee allowances to certain, selected drugs for which reimbursement to the physician is based on the Average Wholesale Price (AWP) of a single dose of an injectable or inhalation drug or the physician's acquisition cost, whichever is less.

iii. Unless otherwise indicated in Subchapter 8 or under the exception listed in (a)2 and 3 below, the Medicaid maximum fee allowance is determined based on the AWP per unit which equals one cubic centimeter (cc) or milliliter (ml) of drug volume for each unit. For drug vials with a volume equal to one cubic centimeter (cc) or milliliter (ml), the Medicaid maximum fee allowance shall be based on the cost per vial.

iv. When a physician office, home, or independent clinic visit is for the sole purpose of administering a drug, the reimbursement shall include the cost of the drug and administration. In these situations, there is no reimbursement for a physician office, home, or independent clinic visit. If, in addition to the physician administration of a drug, the criteria of an office, home, or independent clinic visit is met, the cost of the drug and administration may, if medically indicated, be reimbursed in addition to the visit.

v. No reimbursement will be made for vitamins, liver or iron injections or combination thereof; except in laboratory-proven deficiency states requiring parenteral therapy.

vi. No reimbursement will be made for placebos or any injections containing amphetamines or derivatives thereof.

vii. No reimbursement will be made for injection given as a preoperative medication or as a local anesthetic which is part of an operative or surgical procedure, since this injection would normally be included in the prescribed fee for such a procedure.

2. The second method of reimbursement shall be limited to situations where a drug required for administration has not been assigned a "J" code. In these situations, the drug shall be prescribed and obtained from a pharmacy which directly bills the New Jersey Medicaid/NJ FamilyCare program. In this situation, the physician shall bill only for the administration of the drug using HCPCS 90799.

3. Separate reimbursement shall be available for the administration of drug(s) in accordance with the appropriate procedure codes listed in the Physician's Current Procedural Terminology (CPT).

(b) The drug administered shall be consistent with the diagnosis and conform to accepted medical and pharmacological principles in respect to dosage frequency and route of administration.

(c) In order for physician-administered drugs to be reimbursed by the Medicaid/NJ FamilyCare program, manufacturers must have in effect all rebate agreements required or directed pursuant to all applicable State and Federal laws and regulations. To confirm that a manufacturer has complied with such rebate provisions and that a particular drug manufactured by the manufacturer is eligible for reimbursement, a physician may consult the Medicaid/NJ FamilyCare program's fiscal agent website at: https://www.njmmis.com/ndcLookup.aspx.

(d) Physicians shall report the 11-digit National Drug Code (NDC), quantity of the drug administered or dispensed, and a two-digit qualifier identifying the unit of measure for the medication on the claim when requesting reimbursement. The labeler code and drug product code of the actual product dispensed must be reported on the claim form.

1. The package size code (that is, positions No. 10 and 11 of the NDC) reported may differ from the stock package size used to fill the prescription. Acceptable units of measure are limited to: F2 (international unit); GM (gram); ML (milliliter); and UN (unit/each).

N.J. Admin. Code § 10:54-8.4

Recodified from N.J.A.C. 10:54-8.3 by R.1999 d.232, effective 7/19/1999 (operative September 1, 1999).
See: 31 N.J.R. 245(a), 31 N.J.R. 1956(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 the introductory paragraph of (a), (a)1ii and (a)2, inserted "/NJ FamilyCare program"; in the introductory paragraph of (a), deleted a comma following "home"; rewrote the introductory paragraph of (a)1; in (a)1ii, deleted a comma following "drug"; in (a)2, deleted ", Level III HCPCS procedure code" following "code"; and added (c) and (d).