N.J. Admin. Code § 10:66-6.4

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:66-6.4 - HCPCS procedure codes-qualifiers

(a) Evaluation and management and other procedures:

1. Drawing of blood: 36415.

i. Once per visit, per patient. (Not applicable if laboratory study, in any part, is performed by the clinic.)

2. Photodynamic therapy: 67221 for one eye and 67225 for the second eye at single session.

i. Procedure code 67221 may be billed with 67225. This procedure must be rendered by ophthalmologists who are retinal specialists, and shall be limited to patients meeting the following criteria:

(1) Best corrected visual acuity equal to or better than 20/200, if the decreased visual acuity is caused by the macular degeneration;

(2) Classic subfoveal choroidal neovascularization (CNV), occupying 50 percent or greater of the entire ocular lesion; and

(3) For dates of service before October 1, 2015, a reported ICD-9-CM diagnosis of 115.02, 115.92, 362.21, or 362.52 (exudative senile macular degeneration), or for dates of service on or after October 1, 2015, a reported ICD-10-CM diagnosis of H35.32 or B39.9 w/H32.

ii. Procedure code 67225 must be billed with 67221. This procedure must be rendered by ophthalmologists who are retinal specialists, and shall be limited to patients meeting the criteria set forth in (a)2i(1) through (3) above.

iii. Report HCPCS procedure code 67225 on the CMS 1500 claim form for procedures performed on a second eye when both eyes are treated on the same date of service. Evaluation and management (E&M) services, fluorescent angiography (FA) and other ocular diagnostic services may also be billed separately when determined medically necessary and provided on the same date of service.

iv. Modifiers LT or RT should be used on all claims for codes 67221 and 67225 whether initial or subsequent treatment.

3. Injection (intradermal, subcutaneous, or intra-arterial): 96372 and 96373.

i. Reimbursement for the above injections are on a flat-fee basis and are all inclusive for the cost of the service as well as the materials. Be advised of the following:

(1) A visit for the sole purpose of an injection is reimbursable only as an injection and not as a clinic visit and injection. However, if the criteria of a clinic visit is met, an injection may, if medically indicated, be considered as an add-on to the visit. The drug administered shall be consistent with the diagnosis and shall conform to accepted medical and pharmacological principles with respect to dosage, frequency and route of administration.

(2) Intravenous and intraarterial injections are reimbursable only when performed by the physician.

(3) No reimbursement will be made for vitamins, liver or iron injections or combinations thereof except in laboratory proven deficiency states requiring parenteral therapy.

(4) No reimbursement will be made for placebos or any injections containing amphetamines or derivatives thereof.

(5) No reimbursement will be made for injections given for the treatment of obesity.

(6) No reimbursement will be made for an injection given as a pre-operative medication or as a pre-operative local anesthetic which is part of an operative or surgical procedure since this injection would normally be included in the listed fee for such a procedure.

(7) Insert procedure code 96372 and 96373 as a separate item on the claim, followed by the name, dose of drug, and route of administration. The complete diagnosis, for which the injection was given, shall be indicated on the claim.

4. General clinical psychiatric diagnostic or evaluative interview procedures: 90801.

i. This code requires for reimbursement purposes a minimum of 50 minutes of direct personal clinical involvement with the patient or family member. The CPT narrative otherwise remains applicable.

5. Prolonged detention: 99354 and 99355.

i. Prolonged detention with or without critical care will be covered under CPT 99354 and 99355, but the service shall be consistent with the following narrative in order to be reimbursed:

(1) The patient's situation requires constant physician attendance which is given by the physician to the exclusion of other patients and duties. This must be verified by the applicable records as defined by the setting.

(2) Records shall show in the physician's handwriting the time of onset and time of completion of the service.

ii. This code may not be used simultaneously with procedure codes that pay a reimbursement for the same time or type of service.

iii. The basis for this type of claim should be apparent on the claim form.

6. Evaluation and management--new patient; excludes preventive health care for patients through 20 years of age: 99201, 99201 FP, 99201 FP SB, 99201 SA, 99201 SB, 99201 FP 52, 99202, 99202 FP, 99202 FP SB, 99202 SA, 99202 SB, 99202 FP 52, 99203, 99203 FP, 99203 FP SB, 99203 SA, 99203 SB, 99203 UD, 99203 FP 52, 99204, 99204 FP, 99204 FP SB, 99204 SA, 99204 SB, 99204 FP 52, 99205, 99205 FP, 99205 FP SB, 99205 FP 52, and 99432.

i. When reference is made in the CPT manual to "Office--New Patient," the intent of the Medicaid program is to consider this service as the initial visit.

ii. Reimbursement for an initial clinic visit will be disallowed, if a preventive medicine service, EPSDT examination or clinic consultation were billed within a twelve month period by a clinic.

iii. It is also to be understood that in order to receive reimbursement for an initial visit, the following minimal documentation must be on the record regardless of the setting where the examination was performed. For example:

(1) Chief complaint(s);

(2) Complete history of the present illness and related systemic review, including recordings of pertinent negative findings;

(3) Pertinent past medical history;

(4) Pertinent family history;

(5) A full physical examination pertaining to but not limited to the history of the present illness and includes recording of pertinent negative findings; and

(6) Working diagnoses and treatment plan including ancillary services and drugs ordered.

7. Evaluation and management services--established patient; excludes preventive health care for patients through 20 years of age: 99211, 99211 SA, 99211 SB, 99211 FP, 99211 FP SB, 99211 FP 52, 99212, 99212 FP, 99212 FP SB, 99212 FP 52, 99212 SB, 99212 SA, 99213, 99213 FP, 99213 FP SB, 99213 FP 52, 99213 SB, 99213 SA, 99213 UD, 99214, 99214 FP, 99214 FP 52, 99214 FP SB, 99214 SB, 99214 SA, 99215, 99215 FP, 99215 FP 52, 99215 FP SB, and 99215 SB.

i. Routine visit or follow-up care visit is defined for purposes of Medicaid and NJ FamilyCare fee-for-service reimbursement as the care and treatment by a physician, advanced practice nurse, or certified nurse-midwife, as appropriate, which includes those procedures ordinarily performed during a health care visit, which are dependent upon the setting and the practitioner's discipline.

ii. In order to document the record for reimbursement purposes, a progress note for the noted visits should include the following:

(1) Purpose of visit;

(2) Pertinent history obtained;

(3) Pertinent physical findings including pertinent negative findings based on the above;

(4) Procedures, if any, with results;

(5) Lab, X-ray, EKG, etc., ordered with results; and

(6) Diagnosis.

8. Consultations: A consultation is recognized for reimbursement only when performed by a specialist recognized as such by this Program and the request has been made by or through the patient's attending physician and the need for such a request would be consistent with good medical practice.

i. Comprehensive consultation: 99244, 99245, 99254 and 99255.

(1) In order to receive reimbursement for these HCPCS codes, the performance of a total systems evaluation by history and physical examination, including a total systems review and total system physical examination are required.

(2) An alternative to (a)8i(1) above would be the utilization of one or more hours of the consulting physician's personal time in the performance of the consultation.

(3) The following rules regarding consultations shall also be recognized.

(A) If a consultation is performed and the patient is then transferred to the consultant's service during the course of that illness, the provider may not, in addition, bill for an Initial Visit if he or she has or intends to bill for the consultation.

(B) If there is no referring physician, then an Initial Visit code should be used instead of a consultation code.

(C) If the patient is seen for the same illness on repeated visits, by the same consultant, then these visits are considered as routine visits or follow-up care visits and not as consultations.

(D) Consultation codes will be declined in a clinic setting if the consultation has been requested by or between members of the same group, shared health care facility or physicians sharing common records. A routine visit code is applicable under these circumstances.

(E) If a prior claim for comprehensive consultation visit has been made within the preceding 12 months, then a repeat claim for this code will be denied if made by the clinic except in those instances where the consultation required the utilization of one hour or more of the physician's personal time. Otherwise, applicable codes would be limited consultation code if their criteria are met.

ii. Limited consultation: 99241, 99242, 99243, 99244, 99251, 99252 and 99253.

(1) The area being covered for reimbursement purposes is "limited" in the sense that it requires less than the requirements designated as "comprehensive" as noted above.

iii. Second opinion program consultation: 99244 SM.

(1) A consultation to satisfy the requirements of the mandated "Second Opinion" program will be reimbursed only if the requirements of that program are met and the consultation has been performed by the appropriate board certified specialist who has signed a separate provider agreement and whose selection has been through the Second Opinion Referral Service (1-800-676-6562).

iv. Third opinion consultation: 99244 SN.

(1) In the event that a patient receives two different points of view relative to a "Second Opinion" procedure, he or she may, if unable to reach a decision, request a third opinion.

(2) A third opinion consultation must be at the patient's request and under the circumstances described.

9. Critical care services: 99291 and 99292.

i. Critical care is reimbursable under codes 99291 and 99292 if the service is consistent with the following:

(1) The patient's situation requires constant physician attendance which is given by the physician to the exclusion of his or her other patients and duties and, therefore, represents what is beyond the usual service. This must be verified by the applicable records as defined by the setting and which records must show in the physician's handwriting the time of onset and time of completion of the service.

(2) All settings are applicable, such as clinic and hospital.

(3) These codes may not be used simultaneously with procedure codes that pay a reimbursement for the same time or type of service.

10. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services through age 20: 99382 EP through 99385 EP and 99392 EP through 99395 EP.

i. If performed by an outside independent laboratory, the laboratory must submit the claim. Blood sample for lead screening test should be sent to the New Jersey State Department of Health.

ii. Procedure codes 99382 EP through 99385 EP, for initial visits, shall only be used once for the same patient during any 12-month period by the same physician, group, shared health care facility, or practitioner(s) sharing a common record. Reimbursement for these procedure codes is contingent upon submission of both a completed Report and Claim For EPSDT/HealthStart Screening and Related Procedures (MC-19) and the appropriate claim form within 30 days of the date of service. In the absence of a completed MC-19 form, reimbursement will be reduced to the level of an annual health maintenance examination.

11. Vaccines for Children program: 90465, 90466, 90467, 90468, 90471, 90472, 90473 and 90474. These codes apply only to the administration of vaccines to beneficiaries under 19 years of age who qualify for the Vaccines for Children (VFC) program. These codes must be billed in conjunction with the appropriate HCPCS procedure code for the specific vaccine(s) provided; however, separate reimbursement shall not be provided for the sera because the sera are provided free under the VFC program. See 10:66-2.20.

(b) Dental services (See N.J.A.C. 10:56-3 ).

(c) Family planning services:

1. Norplant--removal, implantable contraceptive capsules: 11976.

i. The maximum fee allowance includes the removal of the subdermal contraceptive implants and the post-removal visit.

2. Sterilization (male): 55250 and 55450.

i. Primary sterilization (family planning) procedure.

ii. A completed consent form shall be attached to the claim form, in accordance with 10:66-2.3.

3. Sterilization (female): 58600, 58605 and 58611.

i. These procedures are always considered a sterilization procedure. Therefore, a completed consent form shall be attached to the claim form, in accordance with 10:66-2.3.

4. Initial medical visit: 99201 FP, 99201 FP SB, 99201 FP 52, 99202 FP, 99202 FP SB, 99202 FP 52, 99203 FP, 99203 FP SB, 99203 FP 52, 99204 FP, 99204 FP SB, 99204 FP 52, 99205 FP, 99205 FP SB and 99205 FP 52.

i. Family planning to include each of the following:

(1) Medical, social, obstetrical history

(2) Complete pelvic examination--including visual inspection of the cervix

(3) Breast examination

(4) Papanicolaou smear (excludes cytology study)

(5) Contraceptive counseling with referral as indicated.

ii. Includes the cost of birth control drugs dispensed. A prescription cannot be substituted. Procedure codes with the "52" modifier do not include the cost of birth control drugs.

iii. These procedure codes (initial medical visit) will be disallowed if procedure codes 99201, 99201 FP, 99201 FP SB, 99201 FP 52, 99202, 99202 FP, 99202 FP SB, 99202 FP 52, 99203, 99203 FP, 99203 FP SB, 99203 FP 52, 99204, 99204 FP, 99204 FP SB, 99204 FP 52, 99205, 99205 FP, 99205 FP SB and 99205 FP 52 have been performed during the prior 12 months by the same provider.

5. Routine or follow-up visit--brief: 99211 FP, 99211 FP SB, 99211 FP 52, 99212 FP, 99212 FP SB, 99212 FP 52, 99213 FP, 99213 FP SB and 99213 FP 52.

i. May include pelvic examination, changes in method or physician's or certified nurse-midwife's instructions at a minimum average time of five minutes, or a visit solely for a refill supply of birth control drugs for which a prescription cannot be substituted and professional contact is not necessary.

6. Medical revisit--family planning: 99214 FP, 99214 FP 52 and 99214 FP SB.

i. May include pelvic examination or changes in method or physician's or certified nurse-midwife's instructions. This code includes the cost of birth control drugs dispensed. A prescription cannot be substituted. Procedure codes with the "52" modifier do not include the cost of birth control drugs.

7. Routine or follow-up visit--prolonged: 99215 FP, 99215 FP 52 and 99215 FP SB.

i. May include pelvic examination or changes in method or physician's or certified nurse-midwife's instructions. Involves 20 or more minutes of personal time in patient contact, including documentation of time as well as adequate significant progress notes on the clinic record. This procedure code includes the cost of birth control drugs dispensed. A prescription cannot be substituted. Procedure codes with the "52" modifier do not include the cost of birth control drugs.

8. Annual medical revisit: 99395 FP and 99395 FP SB.

i. Family planning to include each of the following:

(1) Updating medical, social, obstetrical history;

(2) Complete pelvic examination including visual inspection of cervix;

(3) Breast examination; and

(4) Papanicolaou smear (excludes cytology study) with referral when indicated.

ii. This code includes the cost of birth control drugs dispensed. A prescription cannot be substituted.

iii. Procedure code 99395 FP 22 will be disallowed if procedure codes 99201, 99201 FP, 99201 FP SB, 99201 FP 52, 99202, 99202 FP, 99202 FP SB, 99202 FP 52, 99203, 99203 FP, 99203 FP SB, 99203 FP 52, 99204, 99204 FP, 99204 FP SB, 99204 FP 52, 99205, 99205 FP, and 99205 FP SB have been performed during the prior 12 months by the same provider.

9. Code 36415 FP. This service is reimbursable to the Family Planning Clinic only when the specimen is referred out to an independent clinical laboratory for testing.

Note: Physicians/practitioners and Family Planning Clinics cannot bill when the tests are completed on the premises and are not referred out to independent clinical laboratories.

(d) Laboratory services (See N.J.A.C. 10:61-3 ).

(e) Minor surgery:

1. Acne surgery, including, but not limited to, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules: 10040.

i. Excision must involve the use of a scalpel and an expressor, but not an expressor alone. This code is limited to severe acne. For less than severe acne, utilize the procedure codes for routine office visits.

(f) Mental health services:

1. Comprehensive intake evaluation: 90791 UC; use 90792 UC for physician involved assessment.

i. An initial procedure performed at a mental health clinic to assess a new patient and recommend an appropriate treatment plan or additional diagnostic studies. The procedure includes initial interviews with the patient and other involved individuals, conferences with referral sources, examination of written material provided by the patient or others, staff conferences and written evaluation and treatment plan including recommendations for further consultations, studies or additional information.

ii. Although this procedure may be performed by a single individual, it is expected that it should be a team approach and of one and one-half hours duration.

2. Individual psychotherapy--20- to 30-minute session: 90832 UC and 90833 UC.

i. This code requires, for reimbursement purposes, a minimum of 20 to 30 minutes of direct personal clinical involvement with the patient and/or family member.

3. Individual psychotherapy--45- to 50-minute session: 90834 UC and 90836 UC.

i. This code requires, for reimbursement purposes, a minimum of 45 to 50 minutes of direct personal clinical involvement with the patient and/or family member.

4. Family therapy: 90847 UC.

i. This code requires, for reimbursement purposes, a minimum of 45 to 50 minutes of direct personal clinical involvement with the patient and/or family member. The CPT narrative otherwise remains applicable.

5. Family therapy: 90847 UC 22.

i. This code requires, for reimbursement purposes, a minimum of 80 minutes of direct personal clinical involvement with the patient and/or family member. The CPT narrative otherwise remains applicable.

6. Family conference: 90887 UC.

i. This code requires, for reimbursement purposes, a minimum of 25 minutes of direct personal clinical involvement with patient, family member or caretaker. The CPT narrative otherwise remains applicable.

7. Group psychotherapy: 90853 UC.

i. This code requires, for reimbursement purposes, a minimum of 90 minutes of direct clinical involvement with the patient as a member of a group of which 10 minutes can be used for documentation. The maximum number of the group is eight and the reimbursement is per person, per group session.

8. Health and behavior assessment; initial assessment: 96150 UC.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

9. Health and behavior assessment; re-assessment: 96151 UC.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

10. Health and behavior intervention; individual: 96152 UC.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

11. Health and behavior intervention; group of two or more patients: 96153 UC.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

12. Health and behavior intervention; family, with patient present: 96154 UC.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

13. Health and behavior intervention; family, without patient present: 96155 UC.

i. This code requires, for reimbursement purposes, a minimum of 15 minutes face-to-face with the beneficiary; the provider shall bill for each completed whole 15-minute unit of service.

(g) Obstetrical services (maternity):

1. Total obstetrical care: 59400.

i. Antepartum care consisting of initial antepartum visits and seven subsequent antepartum visits. Specific date of all visits are to be listed on the claim form.

(1) If medical necessity dictates, corroborated by the record, additional visits above seven antepartum may be reimbursed under the procedure codes for routine or follow-up clinic visit. The claim form shall clearly indicate the reason for the medical necessity and date for each listed.

ii. Obstetrical delivery with in-hospital postpartum care with or without low forceps and/or episiotomy or a vaginal delivery full term or premature following completion of at least 28 weeks of gestation or if baby lives over 24 hours.

(1) This shall also include one visit between the 15th and 60th day postpartum day following delivery and out of hospital. Include name of hospital and delivery date on the claim.

2. Vaginal delivery: 59410.

i. Vaginal delivery full term or premature following completion of at least 28 weeks of gestation or if baby lives over 24 hours.

ii. This shall also include one visit between the 15th and 60th postpartum day following delivery and out of hospital. Include name of hospital and delivery date on the claim.

3. Subsequent antepartum visit: 59425 and 59426.

i. Subsequent antepartum visit, provided as a separate procedure. Indicate specific dates of service.

4. Initial antepartum visit: 99203.

i. Initial antepartum visit, provided as a separate procedure.

5. Postpartum care: 59430.

i. Postpartum care rendered by a physician other than delivery physician.

ii. This shall also include one visit between 15th and 60th postpartum day following delivery and out of hospital. Include name of hospital and delivery date on the claim.

6. Total obstetrical care by a certified nurse-midwife: 59400 SB.

i. Total obstetrical care when given by a certified nurse-midwife, including:

(1) Antepartum care consisting of initial antepartum visit and seven subsequent antepartum visits. Specific dates of all visits are to be listed on the claim form.

(2) If medical necessity dictates, corroborated by the record, additional visits above seven antepartum may be reimbursed under the procedure codes for routine or follow-up visit. The claim shall clearly indicate the reason for the medical necessity and date for each code listed.

ii. Obstetrical delivery per vagina with or without episiotomy includes postpartum care when provided by the certified nurse-midwife in the home, birthing center or in the hospital or other inpatient setting.

(1) This applies to a vaginal delivery at full term or premature following completion of at least 28 weeks of gestation or if baby lives over 24 hours.

(2) This shall also include one visit between the 15th and 42nd postpartum day following delivery and out of the hospital. Include delivery date on the claim form.

7. Vaginal delivery by a certified nurse-midwife: 59410 SB.

i. Obstetrical delivery per vagina with or without episiotomy including postpartum care when provided by the certified nurse-midwife in the home, birthing center or in the hospital or other inpatient setting.

(1) This applies to a vaginal delivery at full term or premature following completion of at least 28 weeks of gestation or if baby lives over 24 hours.

(2) This shall also include one visit between the 15th and 42nd post-partum day following delivery and out of hospital. Include delivery date on the claim form.

8. Subsequent antepartum visit provided by a certified nurse-midwife: 59425 SB and 59426 SB.

i. Indicate specific date of service.

9. Initial antepartum visit provided by a certified nurse-midwife: 99203 SB.

i. Initial antepartum visit provided by a certified nurse-midwife provided as a separate procedure.

10. Postpartum care provided by a certified nurse-midwife: 59430 SB.

i. Postpartum care provided by a certified nurse-midwife who is other than the individual who performed the delivery and who is not related to this individual by any financial or contractual arrangement, e.g., group, clinic, employee, etc.

ii. One visit between the 15th and 60th postpartum day following delivery. Include delivery date on the claim provided as a separate procedure.

11. Subsequent antepartum visit(s) provided by an advanced practice nurse: 59425 SA and 59426 SA.

i. Initial antepartum visit provided by an advanced practice nurse provided as a separate procedure.

(h) Podiatry services:

1. Routine or follow-up clinic visit: 99211, 99212, 99213, 99214, and 99215.

i. Routine or follow-up clinic visit. A podiatry service consisting of routine care and treatment by the podiatrist.

ii. Include significant written progress notes and office records which demonstrate positive findings and treatment changes.

2. See N.J.A.C. 10:66-6.2(e), Minor surgery, for additional procedures.

(i) Radiology services:

1. Chest: 71010, 71020, 71030, and 71034.

i. Routine chest X-rays without medical necessity in an office (clinic) are not reimbursable under Program guidelines.

2. Pelvis: 72170.

i. Pelvis X-ray is not eligible for separate payment when performed in conjunction with Complete Lumbosacral Spine X-rays (72110).

3. Hip: 73500 and 73510.

i. Procedure 73520 should be used for bilateral hip X-rays when both hips are X-rayed instead of billing separately for each hip (73500 and 73510).

4. Esophagus with fluoroscopy by the radiologist: 74220.

i. Not eligible for separate payment when performed in conjunction with a GI or Small Bowel Series (74240, 74241, 74245, and 74250).

5. Pelvimetry: 74710.

i. Use of the code for pelvimetry requires written evidence of medical necessity to accompany the claim.

(j) Rehabilitation services:

1. Speech therapy: 92507.

i. Minimum time, 30 minutes. Prior authorization required.

ii. Prescribed by a licensed physician, performed by a qualified speech-language pathologist.

2. Audiometric tests: 92552, 92553, 92557, 92567, 92568, 92572, 92576 and 92582.

i. May be reimbursed when prescribed by a physician and performed by an audiologist.

ii. Tympanometry (92567) and acoustic reflex testing (92568) are reimbursable only to a specialist.

iii. Acoustic reflex testing, 92568, shall include at least two frequencies per ear. Brief reflex screening at one frequency per ear is not reimbursable. Documentation of these tests shall appear in the patient's record.

3. Physical therapy: 97799.

i. Individual treatment session--minimum time, 30 minutes. No more than three patients can be treated simultaneously.

ii. Prior authorization required. Consists of any one or a combination of the following modalities, prescribed by a licensed physician, performed by a qualified physical therapist and related to the patient's active treatment regimen.

(1) Appropriate use of accepted mechanical device such as parallel bar, weights, pulley system, friction wheels, steps, etc.

(2) Graduated range of motion exercises.

(3) Therapeutic ultrasound, only when included as part of other forms of accepted therapy.

(4) Therapeutic use of physical agents other than drugs, including heat, light, water, electricity, and radiation.

(5) Instructions to responsible persons for follow-up procedures between therapy visits.

4. Occupational therapy: 97535.

i. Minimum time, 30 minutes. Prior authorization required.

ii. Prescribed by a licensed physician, performed by a qualified occupational therapist.

(k) Vision care services (See N.J.A.C. 10:62-3).

(l) Transportation services:

1. Transportation, one way: Z0330.

i. Applicable when the clinic transports a beneficiary either to or from the clinic in any one day.

ii. Reimbursement is limited to two trips per day for the same beneficiary by the same clinic.

2. Per trip, flat rate, one way trip: A0425.

i. Shall be billed in conjunction with Z0330 when the clinic transports a beneficiary either to or from a Partial Care program in any one day.

ii. Reimbursement is limited to two one-way trips per day for the same beneficiary, by the same clinic, to the same Partial Care program.

(m) Drug treatment center services:

1. Family therapy rendered in a substance use disorder treatment facility: Z2000.

i. A per diem payment based on the number of days a beneficiary is supplied methadone during the billing period. This rate includes the cost of the drug, packaging, nursing time, and administrative costs.

2. Family conference rendered in a substance use disorder treatment facility: Z2001.

i. Therapy with the patient and with one or more family members present. Verbal or other therapy methods are provided by a physician, or a professional counsellor under the direction of a physician, in personal involvement with the patient and the family to the exclusion of other patients and/or duties.

ii. A minimum session of one and one half hours is required with a minimum of 80 minutes personal involvement with the patient and the family and up to 10 minutes for the recording of data.

iii. The clinic may bill only for the patient and not for other family members.

3. Prescription visit rendered in a substance use disorder treatment facility: Z2002.

i. Meeting with the family or other significant persons to interpret or explain medical, psychiatric or psychological examinations and procedures, other accumulated data and/or advice to the family or other significant persons on how to assist the patient.

ii. A minimum of 50 minutes of personal involvement with the family is required. The clinic may bill only for the patient and not for other family members.

4. Psychotherapy rendered in a substance use disorder treatment facility-full session: Z2003.

ii. A minimum session of one and one half hours is required with a minimum of 80 minutes personal involvement with the patient and the family and up to 10 minutes for the recording of data.

iii. The clinic may bill only for the patient and not for other family members.

5. Group therapy rendered in a substance use disorder treatment facility, per person: Z2004.

ii. A minimum of 50 minutes of personal involvement with the family is required. The clinic may bill only for the patient and not for other family members.

6. Psychological testing rendered in a substance use disorder treatment facility, per hour; maximum of five hours: Z2005.

i. A visit with a physician for review and evaluation of the medication history of the patient and the writing, or renewal of prescription, as necessary.

7. Methadone treatment rendered in a substance use disorder treatment facility: Z2006.

i. Verbal, drug augmented, or other therapy methods provided by a physician, or a professional counsellor under the direction of a physician, in a personal involvement with one patient to the exclusion of other patients and/or duties.

ii. A minimum of 50 minutes personal involvement with the patient is required. This includes a prescription visit when necessary.

8. Psychotherapy rendered in a substance use disorder treatment facility--half session: Z2007.

i. Verbal or other therapy methods provided by one or more physicians, or professional counsellors under the direction of physician, in a personal involvement with two or more patients, with a maximum of eight patients.

ii. A minimum session of one and one half hours is required. This includes preparation time in addition to the one and one half hours session time.

9. Urinalysis for substance use disorder treatment facility: Z2010.

i. Psychometric and/or projective tests with a written report.

ii. To be used only by a substance use disorder treatment facility specifically approved by the Program to provide this service.

10. Methadone treatment rendered in a drug treatment center: Z2006.

11. Family therapy rendered in a substance use disorder treatment facility for a WFNJ/SAI-eligible beneficiary: Z3348. Prior authorization is required.

i. Verbal, drug augmented, or other therapy methods provided by a physician, or a professional counsellor under the direction of a physician in a personal involvement with one patient to the exclusion of other patients and/or duties.

ii. A minimum of 25 minutes personal involvement with the patient is required. This includes a prescription visit when necessary.

12. Family conference rendered in a substance use disorder treatment facility for a WFNJ/SAI-eligible beneficiary: Z3349. Prior authorization is required.

i. To determine what level, if any, a drug is present in the urine.

ii. To be used only by a drug treatment center specifically approved by the Program to provide this service.

13. Prescription visit rendered in a substance use disorder treatment facility for a WFNJ/SAI-eligible beneficiary: Z3353. Prior authorization is required.

i. Once per visit per patient. Not applicable if lab study, in any part, is to be performed by the clinic.

14. Psychotherapy rendered in a substance use disorder treatment facility-full session for a WFNJ/SAI-eligible beneficiary: Z3354. Prior authorization is required.

i. Therapy with the patient and with one or more family members present. Verbal or other therapy methods are provided by a physician, or a professional counselor under the direction of a physician, in personal involvement with the patient and the family to the exclusion of other patients and/or duties.

ii. A minimum session of one and one half hours is required with a minimum of 80 minutes personal involvement with the patient and the family and up to 10 minutes for the recording of data.

iii. The clinic shall bill only for the patient and not for other family members.

15. Group therapy rendered in a substance use disorder treatment facility, per person for a WFNJ/SAI-eligible beneficiary: Z3355. Prior authorization is required.

ii. A minimum of 50 minutes of personal involvement with the family is required. The clinic shall bill only for the patient and not for other family members.

16. Psychological testing rendered in a substance use disorder treatment facility, per hour; for a WFNJ/SAI-eligible beneficiary: Z3356. Prior authorization is required.

i. A visit with a physician for review and evaluation of the medication history of the patient and the writing or renewal of prescription, as necessary.

17. Methadone treatment rendered in a substance use disorder treatment facility for a WFNJ/SAI-eligible beneficiary: Z3357. Prior authorization is required.

i. Verbal, drug augmented, or other therapy methods provided by a physician, or a professional counselor under the direction of a physician, in a personal involvement with one patient to the exclusion of other patients and/or duties.

ii. A minimum of 50 minutes personal involvement with the patient is required. This includes a prescription visit when necessary.

18. Psychotherapy rendered in a substance use disorder treatment facility-half session for a WFNJ/SAI-eligible beneficiary: Z3358. Prior authorization is required.

i. Verbal or other therapy methods provided by one or more physicians, or professional counselors under the direction of physician, in a personal involvement with two or more patients, with a maximum of eight patients.

ii. A minimum session of one and one-half hours is required. This includes preparation time in addition to the one and one half hours session time.

19. Urinalysis for drug addiction rendered in a substance use disorder treatment facility for a WFNJ/SAI-eligible beneficiary: Z3359. Prior authorization is required.

i. Psychometric and/or projective tests with a written report are included in the reimbursement.

ii. To be used only by a substance use disorder treatment facility specifically approved by the WFNJ/SAI Program to provide this service.

(n) Miscellaneous services:

1. Termination of pregnancy: 59840 and 59841.

i. See N.J.A.C. 10:66-2.16; FD-179 form shall be attached to the claim form.

ii. For claims submitted by ambulatory surgical centers only, the trimester of pregnancy shall be identified on the claim form by using modifier UA for first trimester or UB for second trimester.

N.J. Admin. Code § 10:66-6.4

Amended by 48 N.J.R. 962(b), effective 6/6/2016

Amended by 49 N.J.R. 1405(a), effective 6/5/2017