New Jersey Administrative Code

(a) A consultation shall include a personal examination of the patient with a written report of the history, physical findings, diagnosis, and recommendations of the consultant for future management. (b) When a consultation is requested from an approved State agency, a letter of …

"Consultation (Limited)" refers, generally, to a single body system review and physical examination. While a limited consultation is not necessarily limited to a single body system, it does not include a complete, total, all inclusive history and complete, total, all inclusive ph…

"Consultation (Comprehensive)" means a total body system evaluation by history and physical examination, including a total body systems review and total body system physical examination. If the total body system evaluation is not performed, reimbursement for comprehensive consult…

"Consultation (Follow-up)" means the monitoring of progress, recommending management modifications or advising on a new plan of care in response to changes in the patient's status. If the physician consultant has initiated treatment at the initial consultation and participates th…

When the examination of the beneficiary is by the same physician, a practitioner, a shared health facility or group of physicians/practitioners who share a common record, the examination is considered that of a single provider. Notes N.J. Admin. Code § 10:54-4.3 Recodified from N…

(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. …

(a) Concurrent care shall be reimbursed where medical necessity requires the services of more than one physician of the same or differing discipline or specialty, in addition to the primary or attending physician, for example: 1. A critically ill patient with diverse medical cond…

(a) This rule applies when a physician is providing concurrent care with an advanced practice nurse whether employed as part of a group, or if the physician provides collaboration to the APN. (b) When an APN is employed by a physician/practitioner group, the Medicaid/NJ FamilyCar…

A physician may bill the Medicaid/NJ FamilyCare program directly for medical care provided in a birth center. These services may include assistance or consultation related to the delivery or pediatric medical care or a pediatric consultation to the infant. All services provided m…

(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…

(a) This rule applies to office, inpatient or outpatient services to established patients (excluding preventive health care for patients through 20 years of age). (b) "Routine visit" or "follow-up visit" means the care and treatment by a physician, which includes those procedures…

(a) "House call" means a physician visit limited to the provision of medical care to an individual who is too ill to go to a physician's office and/or is "home bound" due to his or her physical condition. (b) The house call codes do not distinguish between specialist and non-spec…

(a) When a physician sees his or her patient in the emergency room instead of his or her office, the physician shall use the same codes for the visit that would be used if the patient were seen in the physician's office (HCPCS 99211-99215 only). Records of the emergency room visi…

(a) For critical care services to be covered by the Program, the HCPCS codes 99291 and 99292 shall be used and the service shall be consistent with the following requirement in order to be reimbursed:1. The patient's situation requires constant physician attendance which is given…

(a) For neonatal intensive care services to be covered by the Program, the codes HCPCS 99295-99297 shall be used and the service shall be consistent with the narrative in the CPT and with the following, in order to be reimbursed: 1. The patient's situation requires constant physi…

(a) The New Jersey Medicaid/NJ FamilyCare program shall reimburse durable medical service providers for the use of home apnea monitors under the provisions of N.J.A.C. 10:59 and N.J.A.C. 10:54-5.2 and 5.3. (b) When an order or prescription for a home apnea monitor is received by …

(a) EPSDT screening services shall be provided periodically according to the following schedule which reflects the age of the child: 1. Under six weeks; two months; four months; six months; nine months; 12 months; 15 months; 18 months; 24 months; and annually through age 20 years…

(a) Vision screening shall include the following: 1. A newborn examination including general inspection of the eyes, visualization of the red reflex and evaluation of ocular motility; 2. An appropriate medical and family history; 3. An evaluation, by age six months, of eye fixati…

(a) Dental screening shall include the following: 1. An intraoral examination which is an integral part of a general physical examination meaning observation of tooth eruption, occlusion pattern, and presence of caries or oral infection; 2. A formal referral to a dentist is recom…

(a) An individual hearing screening should be administered annually to all children through age eight and to all childen at risk of hearing impairment; and (b) In addition to what is required in (a) above, after eight years of age, children shall be screened every other year. (c)…

(a) EPSDT providers may apply to the New Jersey Department of Health and Senior Services for certification as Pediatric HealthStart providers. (b) HealthStart is a program of enhanced maternity care and preventive health care for children under 2 years of age. Certified Pediatric…

(a) Payment shall be made for medically necessary family planning services, including medical history and physical examination (including pelvis and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical super…

(a) The following groups or programs of services or programs are included under Home Care Services: 1. Home Health Services (HH); 2. Personal Care Assistant Services (PCA); and 3. Home and Community-Based Services Waiver programs, including: i. Global Options for Long-Term Care (…

(a) Medicaid reimbursement shall be limited to home health services provided by Medicare-certified, New Jersey State Department of Health and Senior Services-licensed home health agency that is a participating provider in the New Jersey Medicaid/NJ FamilyCare program. (See N.J.A.…

(a) Personal care assistant services may be provided by a Medicare-certified, licensed home health agency or by an accredited proprietary or voluntary non-profit homemaker agency approved to participate as a provider of services in the New Jersey Medicaid/NJ FamilyCare program, i…

(a) Financial eligibility for Medicaid for Home and Community-Based Services Waiver programs will be determined by either the county welfare agency (CWA) or by the Social Security Administration. (b) Clinical eligibility for Medicaid for Home and Community-Based Services Waiver p…

(a) "Clinical laboratory services" means professional and technical laboratory services performed by a clinical laboratory certified by CMS in accordance with the Clinical Laboratory Improvement Act (CLIA) and ordered by a physician or other licensed practitioner (including the c…

(a) Individuals served in the Home and Community-Based Services Waiver program shall be medically in need of nursing facility care, as determined by the professional staff designated by the Department of Health and Senior Services but elect to remain at home with community-based …

(a) Community Resources for People with Disabilities (CRPD) Waiver Services offer all New Jersey (Title XIX) Medicaid services except nursing facility services. In addition to all regular Medicaid services, the following services may be offered as part of CRPD services: 1. Case/c…

(a) The AIDS Community Care Alternatives Program (ACCAP) offers all New Jersey (Title XIX) Medicaid services, except nursing facility services to children and adults with the AIDS diagnosis and to children up to the age of five who are HIV positive. In addition to all regular Med…

(a) The Global Options (GO) waiver program offers all New Jersey (Title XIX) Medicaid services, to eligible adults age 65 years of age and older and to adults between the ages of 21-64, who are permanently physically disabled. In addition to all regular Medicaid services, a GO pa…

(a) The Home and Community-Based Services Waiver for Persons with Traumatic Brain Injuries (TBI) offers home and community-based services to a beneficiary with an acquired traumatic brain injury to help him or her remain in the community, or return to the community rather than be…

Notes N.J. Admin. Code § 10:54-5.25 Repealed by R.2012 d.124, effective 7/2/2012. See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a). Section was "Home Care Services; Home and Community-Based Waiver for Medically Fragile Children (ABC Program)".

The Home and Community-Based Care Waiver for Mentally Retarded/Developmentally Disabled (CCW) offers all New Jersey (Title XIX) Medicaid services, except nursing facility services, to eligible mentally retarded individuals receiving services from the Division of Developmental Dis…

Notes N.J. Admin. Code § 10:54-5.27 Repealed by R.2012 d.124, effective 7/2/2012. See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a). Section was "Home Care Services; Home Care Expansion Program (HCEP)".

For the policy related to private duty nursing services in a home setting for Medicaid/NJ FamilyCare program beneficiaries of EPSDT services, see Home Care Services, N.J.A.C. 10:60-1.3(b) and 1.12(b) and (c). Notes N.J. Admin. Code § 10:54-5.28 Amended by R.2001 d.51, effective 2…

(a) The New Jersey Medicaid/NJ FamilyCare program provides hospice services under N.J.A.C. 10:60-2.15(a)7 and 3.16(a)7, the AIDS Community Care Alternatives Program (ACCAP) and N.J.A.C. 10:53A-3.4, hospice services to other Medicaid beneficiaries. (b) Hospice care under the ACCAP…

(a) Cosmetic surgery means that surgery, which is performed solely for the purpose of beautifying an individual and which has no significant redeeming medical necessity. For purposes of the New Jersey Medicaid/NJ FamilyCare program, cosmetic surgery is not a covered or reimbursab…

(a) "Medical supplies" means item(s), which are: 1. Consumable, expendable, disposable or non-durable; 2. Prescribed by the physician or practitioner (See N.J.A.C. 10:59-1.2 for further description); and 3. Medically necessary for use by a Medicaid/NJ FamilyCare program beneficia…

(a) An attending physician shall prescribe, and certify in the medical record, the medical necessity for nursing facility services for a Medicaid/NJ FamilyCare program patient. (b) When physician services are provided to a patient in a nursing facility (formerly known as a skille…

(a) The Division covers services rendered and items dispensed or furnished in connection with organ procurement and transplantation services of kidney, heart, heart-lung, liver, bone marrow, cornea and other selected medically necessary organ transplants except those transplants …

(a) For purposes of the New Jersey Medicaid/NJ FamilyCare program, "an orthopedic shoe" means footwear, with or without accompanying appliances, used to prevent or correct gross deformities of the feet, which is properly fitted as to length and width, and consists of the followin…

(a) Custom-made prosthetic and orthotic appliances (required to replace, support or strengthen parts of the body) are allowable when prescribed by a licensed physician. For purpose of the New Jersey Medicaid/NJ FamilyCare program, "custom-made" means a device or appliance fabrica…

(a) Rehabilitative services include physical therapy, occupational therapy, and speech-language pathology and audiology, including the use of such supplies and equipment as are necessary in the provision of such services. Rehabilitative services and other restorative services are…

(a) Physical therapy is a service prescribed by a physician and provided to a Medicaid/NJ FamilyCare beneficiary by or under the direction of a qualified physical therapist. Physical therapy does not include therapy which is purely palliative, such as the application of heat in a…

(a) Occupational therapy is a service prescribed by a physician and provided to a Medicaid/NJ FamilyCare beneficiary by or under the direction of a qualified occupational therapist and includes the necessary supplies and equipment. 1. A qualified occupational therapist is an indi…

(a) Speech-language pathology services and audiology services are diagnostic, screening, preventive, or corrective services prescribed by a physician and provided to a Medicaid/NJ FamilyCare beneficiary by or under the direction of a speech-language pathologist or audiologist. Th…

(a) No portion of the time spent on therapy treatments may be considered as part of the time parameters of an office visit. Office visits billed during the same day shall clearly and separately meet the time and other parameters described in the applicable HCPCS procedure codes, …

Payment for endoscopic procedures shall be made in accordance with N.J.A.C. 10:54-5.5, 5.6, and 5.9. Notes N.J. Admin. Code § 10:54-5.4

(a) A second opinion shall be required for the elective surgical procedures listed under (b) below. The outcome of the second opinion will have no bearing on payment. Once the second opinion is rendered, the patient will retain the right to decide whether or not to proceed with t…