New Jersey Administrative Code

(a) Extractions--includes local anesthesia and routine post-operative care: Maximum Fee HCPCS Allowance IND Code Mod Procedure Description S $ NS D7110 Single Tooth 32.00 30.00 D7120 Extraction--each additional tooth 32.00 30.00 D7130 Root Removal--Exposed Roots 19.50 18.00 NOTE …

(a) Minor treatment for tooth guidance:1. Includes all necessary adjustments. 2. Code may also be used for Orthodontic Retention Appliances following comprehensive treatment by a previous dentist. Maximum Fee HCPCS Allowance IND Code Mod Procedure Description S $ NS D8010 Limited…

(a) Unclassified treatment: Maximum Fee HCPCS Allowance IND Code Mod Procedure Description S $ NS d D9110 Palliative (Emergency) Treatment 10.00 9.00 of Dental Pain--Minor Procedures NOTE: Emergency treatment of dental pain or infection, palliative (flat fee for all services perf…

(a) Clinical Oral Examination: Maximum Fee HCPCS Allowance IND Code Mod Procedure Description S $ NS D0150 Comprehensive oral evaluation 15.00 14.00 NOTE 1: This code is to be used for comprehensive clinical oral evaluation of a Medicaid/NJ FamilyCare fee-for-service beneficiary.…

(a) Dental prophylaxis: Click here to view image. NOTE: Patients 16 years of age or older, maxillary and mandibular arches; includes additional scaling. Click here to view image. NOTE 1: Patients 16 years of age or older, maxillary or mandibular arch, includes additional scaling.…

(a) Amalgam restorations (including polishing): Maximum Fee HCPCS Allowance IND Code Mod Procedure Description S $ NS D2110 Amalgam--One Surface, Primary 32.00 30.00 D2120 Amalgam--Two Surfaces, Primary 38.00 35.50 D2130 Amalgam--Three Surfaces, Primary 44.00 41.00 D2131 Amalgam-…

(a) Therapeutic Pulpotomy: Maximum Fee HCPCS Allowance IND Code Mod Procedure Description S $ NS D3220 Therapeutic Pulpotomy (Excluding 28.00 26.00 Final Restoration)--removal of pulp coronal to the Dentinocemental junction and application of medicament D3221 Gross pulpal debride…

(a) Surgical services (including usual post-operative services): Maximum Fee HCPCS Allowance IND Code Mod Procedure Description S $ NS # D4210 Gingivectomy or Gingivoplasty--Per 43.60 37.50 Quadrant * D4211 Gingivectomy or Gingivoplasty--Per 6.00 5.50 Tooth NOTE 1: Maximum number…

(a) Complete dentures (including six months post delivery care): Maximum Fee HCPCS Allowance IND Code Mod Procedure Description S $ NS * D5110 Complete Denture--Maxillary 334.00 302.00 NOTE: Including denture I.D. * D5120 Complete Denture--Mandibular 342.00 311.00 NOTE: Including…

(a) Treatment prosthesis: Maximum Fee HCPCS Allowance IND Code Mod Procedure Description S $ NS D5931 Obturator prosthesis, surgical 250.00 250.00 D5936 Obturator prosthesis, interim 200.00 200.00 D5937 Trismus appliance (not for TMD 125.00 125.00 treatment) D5951 Feeding aid 500…

(a) Each abutment and each pontic constitutes a unit in a bridge. 1. The Noble Metal Classification System has been adopted as a more precise method of reporting various alloys used in dentistry. The alloys are defined on the basis of the percentage of noble metal content. High P…

(a) This chapter is concerned with the provision of podiatric services by a person licensed to practice podiatry in accordance with the New Jersey Medicaid/NJ FamilyCare programs, policies, and procedures and the standards of practice as defined by the laws of the State of New Je…

Podiatry care under the Medicaid/NJ FamilyCare programs is allowable to covered persons if such services are essential. Essential podiatric care includes those services that require the professional knowledge and skill of a licensed podiatrist. For beneficiaries in the Medically …

The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise. "CPT" means that edition of the Current Procedural Terminology most current at the time of reference, as published annually by the American …

(a) In order to participate in the Medicaid/NJ FamilyCare programs, a podiatrist shall apply to, and be approved by, the New Jersey Medicaid/NJ FamilyCare program. Application for approval by the New Jersey Medicaid/NJ FamilyCare program requires completion and submission of the …

(a) Authorization by the Podiatry Services Unit ("Unit"), Division of Medical Assistance and Health Services, PO Box 712, Trenton, New Jersey 08625-0712, shall be obtained prior to the provision of the following services: 1. All orthopedic footwear; 2. Custom molded foot or ankle…

(a) Reimbursement for podiatry services covered under the New Jersey Medicaid/NJ FamilyCare fee-for-service program shall be on the basis of the customary charge, not to exceed a fixed fee schedule determined reasonable by the Commissioner, Department of Human Services (see N.J.A…

(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D are set forth at N.J.A.C. 10:49-9. (b) Personal contribution to care for NJ FamilyCare-Plan C services is $5.00 per visit for podiatric …

(a) Podiatrists shall keep such individual records as are necessary to fully disclose the kind and extent of the services provided and shall make such information available as the Division or its agents may request. For the initial examination, the following documentation shall b…

(a) The following foot care services shall not be covered: 1. Flat-foot conditions: i. Exceptions: (1) Treatment which is an integral part of post-fracture or postoperative treatment plan; (2) Supportive devices (for example, arch supports, specific additions to shoes and the lik…

(a) Podiatry services rendered in a residential or medical facility (that is, hospital, nursing home, or extended care facility) shall be based on referral by the attending physician. (b) Multiple visits to patients in the same health facility or congregate living arrangement wil…

(a) The New Jersey Medicaid/NJ FamilyCare fee-for-service program shall reimburse podiatrists for certain approved drugs administered intradermally, subcutaneously, intra-muscularly, or intravenously in the office, home, or independent clinic setting according to the following re…

All covered pharmaceutical services provided under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall be provided to New Jersey Medicaid/NJ FamilyCare fee-for-service beneficiaries within the scope of N.J.A.C. 10:49, Administration, and 10:51, Pharmaceutical Ser…

(a) For pharmacy claims with service dates on or after September 1, 1999, which exceed Prospective Drug Use Review (PDUR) standards recommended by the New Jersey Drug Utilization Review Board (NJ DURB) and approved by the Commissioners of DHS and DOH, the Division of Medical Assi…

(a) For purposes of reimbursement, a podiatrist and/or physician; podiatrist and/or physicians' group; shared health care facility; or providers sharing a common record are considered a single provider. (b) When reference is made in the CPT manual to Office or other outpatient se…

(a) Specific requirements for surgery procedures may be found at N.J.A.C. 10:57-3.2(b). 1. Certain surgical procedures are carried out as an integral part of a total service and, as such, do not warrant a separate charge. When such a procedure is carried out as a separate entity …

(a) Specific requirements for radiology procedures may be found at N.J.A.C. 10:57-3.2(c). 1. Reimbursement will be made for the combined technical and professional component of the reimbursement for the procedure code notwithstanding any statement to the contrary in the narrative…

(a) A consultation is recognized for reimbursement only when performed by a specialist, as the term is defined at N.J.A.C. 10:57-1.3, who is recognized as such by this Program and the request has been made by or through the patient's attending physician or other licensed practiti…

(a) Payment will be allowed for orthotic services rendered by a podiatrist for his or her own patients with prior authorization (See N.J.A.C. 10:57-1.5). (b) Services provided by a prosthetic and orthotic (P&O) facility must be billed directly to the program by the P&O facility, …

(a) "Clinical laboratory services" means professional and technical laboratory services performed by a clinical laboratory certified by the Centers for Medicare & Medicaid Services (CMS) in accordance with the Clinical Laboratory Improvement Act (CLIA) and ordered by a physician …

(a) A hospital-based podiatrist who is salaried and whose services are reimbursed as part of the hospital's cost shall not bill fee-for-service to the New Jersey Medicaid/NJ FamilyCare program. 1. A podiatrist practicing in the hospital outpatient department, whose reimbursement …

Payment will be allowed for necessary radiological services by a podiatrist, subject to the limitations of his or her licensure. Routine X-rays for screening purposes shall not be reimbursed. Notes N.J. Admin. Code § 10:57-2.9

(a) The New Jersey Medicaid and NJ FamilyCare programs use the Federal Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accoun…

(a) MEDICINE IND HCPCS Code Mod Maximum Fee Allowance S $ NS Anes Basic Units 90703 17.72 3.40 93922 22.00 21.00 93922 26 9.00 8.00 93922 TC 13.00 13.00 93923 45.00 42.00 93923 26 18.10 15.10 93923 TC 26.90 22.00 93965 30.00 28.00 93965 26 12.00 10.00 93965 TC 18.00 18.00 93970 6…

IND HCPCS Code Mod Description S Maximum Fee Allowance $ NS G0001 Routine venipuncture 1.80 1.80 QUALIFIER: This service is reimbursable in the provider office laboratory (POL) when the specimen is referred out to an independent clinical laboratory for testing. Venipuncture is no…

(a) The following is a list of HCPCS codes with their associated qualifiers. Providers shall use the following procedure codes in billing each of the procedures. 1. HCPCS 36415--Maximum units per date of service is 10. Not applicable if the laboratory study, in any part, is perfo…

Notes N.J. Admin. Code § 10:57-3.5 Recodified to N.J.A.C. 10:57-3.4 by R.2006 d.240, effective 7/3/2006. See: 38 N.J.R. 1126(a), 38 N.J.R. 2805(a). Section was "Qualifiers for podiatry services".

The purpose of this chapter is to provide the standards for approval of certified nurse midwives as independent providers of services, within their licensed scope of practice and in accordance with the requirements of N.J.A.C. 13:35-2A, to New Jersey Medicaid/NJ FamilyCare-Plan A…

(a) In order to receive reimbursement for an initial visit, the following documentation, at a minimum, shall be on the record, regardless of the setting where the examination was performed: 1. The chief complaint(s); 2. A complete history of the present illness and related system…

(a) In order to document the record for reimbursement purposes, the progress note for routine office visits or follow-up care visits shall include the following: 1. In an office: i. The purpose of the visit; ii. Pertinent history obtained; iii. Pertinent physical findings, includ…

(a) To qualify as documentation that the service was rendered by the practitioner during a hospital inpatient stay, the medical record shall contain the CNM's notes, indicating that the practitioner personally: 1. Reviewed the patient's medical history with the patient and/or his…

(a) For individuals under 21 years of age, the following shall be performed and documented in the beneficiary's record:1. A history (complete initial for new patient, interval for established patient) including past medical history, family history, social history, and systemic re…

(a) The record and documentation of a home visit or house call shall become part of the office progress notes and shall include, as appropriate, the following information: 1. The purpose of the visit; 2. The pertinent history obtained; 3. Pertinent physical findings, including pe…

(a) Medical records maintained by a birth center for the maternity services shall include, but not be limited to:1. Patient identification; 2. An initial medical history, results of physical examination, and diagnosis; 3. Progress notes for each visit, which shall include interim…

(a) The rules in this chapter govern reimbursement made directly to a nurse midwife provider. Reimbursement shall not be made to a certified nurse midwife unless the nurse midwife has been approved as a Medicaid/NJ FamilyCare provider, in accordance with the provisions of this ch…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context indicates otherwise. "Birth center" means a health care facility or distinct part of a health care facility, licensed as such by the New Jersey State Department of Heal…

(a) Any nurse midwife may apply to the New Jersey Medicaid/NJ FamilyCare programs for approval as a Medicaid/NJ FamilyCare provider, if he or she: 1. Is a registered professional nurse licensed by the New Jersey State Board of Nursing; 2. Is certified by the American College of N…

(a) A certified nurse midwife who is a Medicaid/NJ FamilyCare provider may also become a HealthStart Comprehensive Maternity Care or HealthStart Maternity Medical Care services provider. (b) In order to participate as a provider of HealthStart services, the CNM practicing indepen…

(a) A birth center shall enroll as a CNM provider in order to receive reimbursement for the use of the facility for labor and delivery services provided at the center. (b) The birth center shall be licensed by the Department of Health in accordance with the provisions at N.J.A.C.…

(a) Reimbursement for certified nurse midwifery services shall be based upon the provider's usual and customary charge or the allowance determined by the Commissioner of the Department of Human Services and contained in N.J.A.C. 10:58-3, whichever is less. (b) A certified nurse m…