The full text of the current Fee Schedule rule can be found in MS Word and Acrobat file form and its seven exhibits can be found in both MS Excel and Acrobat file form on the Department’s web site at: www.state.nj.us/dobi/pipinfo/aicrapg.htm#medfeesched. Also on this web page are any recent proposals, adoptions or information about the rules. Older material can be found located by clicking on the link entitled “Reference/Superceded Material."

A hard copy of the current fee schedule rule is available from the Department for a copying fee of $10. Requests should be sent to:

Office of Legislative and Regulatory Affairs
NJ Department of Banking and Insurance
20 West State Street
P.O. Box 325
Trenton, NJ 08625

The list of zip codes comprising the North and South Regions can be found in the text of the fee schedule rule at 11:3-29.3.

Fee Schedule Rule - PDF or MS Word (Effective for treatment rendered on or after January 4, 2013)

The recent amendments to the Physicians’ fee schedule include around 1,500 CPT and HCPCS codes. However, there will be some CPT/HCPCS codes that are not included. The text of the rule at N.J.A.C. 11:3-29.4(e) states the rules for how fees for services that do not have fees in the Physicians’ fee column of Appendix, Exhibit 1 should be calculated.

N.J.A.C. 11:3-29.5(a) states that services for which there is no fee in the ASC facility fee column of Appendix, Exhibit 1 are not reimbursable if performed in an ASC. Stated another way, the only facility fees for services that are reimbursable if performed in an ASC are those CPT and HCPCS codes that have facility fees listed in the ASC facility fee column of Appendix, Exhibit 1. HOWEVER, the Department inadvertently omitted the “N1” payment indicator from a number of services in Appendix, Exhibit 1 that are performed in ASCs. These “N1” payment indicators are found in CMS’ Addendum AA - Final ASC Covered Surgical Procedures for CY 2011 (MS Excel); PDF version.

The “N1” payment indicator means that the service can be performed in an ASC but is not separately reimbursable because the service is included in another procedure. The list of codes for which the “N1” payment indicator should have been included in Appendix, Exhibit 1 can be found here (MS Excel) (or PDF version).

Please bring these cases to the attention of the Department and we will determine if the old codes for the service can be crosswalked to the new codes. Codes can be crosswalked when the service described by the new code is substantially the same as that for the old code and Medicare still permits the service to be performed in an ASC. The fees for crosswalked services are those for the old codes. Below is a list of crosswalked codes for the ASC facility fee column of Exhibit 1:

The text of the rule does not include any restriction on the procedures that can be performed in an HOSF. The fees for services that are not on the HOSF fee schedule, Appendix, Exhibit 7, should be determined according to the text of the rules in N.J.A.C. 11:3-29.4(a) and 11:3-29.4(e).

The provider should always bill the actual and correct CPT code that he or she is providing. The amount that the insurer pays for the service is determined by the provisions of N.J.A.C. 11:3-29.4(e).

As stated in the text of the rule at N.J.A.C. 11:3-29.4(m), the limit of the insurer’s liability for the CPT codes listed in Appendix, Exhibit 6 per day is $105.00. Therefore, it applies regardless of the number of providers that the injured person visits.

No. For the CPT codes that are subject to the daily maximum, the insurer’s limit of liability is the lesser of:

1. the sum of the provider’s usual reasonable and customary fees for the services provided without applying the reduction formula but with the application of NCCI edits; or

2. the $105.00 daily maximum.

No. As stated in the text of the rule at N.J.A.C. 11:3-29.4(f), the multiple procedures reduction formula applies only to the fees in the Physicians’ Fee column for multiple and bilateral surgeries (CPT 10000 through 69999).

13.

The fee schedule rule follows the practice used by the American Medical Association in developing the CPT system. The text of the rule at N.J.A.C. 11:3-29.4(l) states that:

"The professional component of global service charges shall be reported using modifier -26 as designated in CPT. Services with professional component amounts of zero in the fee schedule are considered to be 100 percent technical. The technical component is the difference between the global service and the professional component amounts listed in the fee schedule."

The definitions section of the rule states that, “'Global Service' means the sum of the technical and professional components.”

The CPT manual states that "a modifier provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. The judicious application of modifiers obviates the necessity for separate procedure listings that may describe the modifying circumstance." The manual goes on to say that, "Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier '-26' to the usual procedure number,' and offers the following example, "a physician providing diagnostic or therapeutic radiology services, ultrasound or nuclear medicine services in a hospital would use modifier '-26' to report the professional component."

As is indicated in the rule and the explanatory text in the CPT manual, it was the Department’s intent in drafting the rule that in no case would a provider bill more than the global fee but that in some instances a provider would only bill for the professional service, if, as in the example in the CPT manual, the technical component was provided by some other entity, such as a hospital.

The explanation for the reimbursement of anesthesia services can be found in the text of the rule at N.J.A.C. 11:3-29.4(p).

No. The procedures concerning billing for bilateral and co-surgeries and exemptions from the multiple procedure reduction formula listed in N.J.A.C. 11:3-29.4(f) are intended to apply only to services billed pursuant to the Physicians’ fees column in Appendix, Exhibit 1. The multiple procedure reduction and bilateral procedures rule for ASCs and HOSFs are found in the text of the rule at N.J.A.C. 11:3-29.5(d).

If a provider gives an insurer the opportunity to review and preauthorize the use of an unlisted code by means of a decision point review or precertification request as the Department has requested, the insurer should take that opportunity to make a determination on the use of the unlisted service during the review period or request additional information. Absent some extraordinary circumstance, an insurer should not recode an unlisted service after it has been approved to be performed. However, this does not apply to the various procedures listed in N.J.A.C. 11:3-29.4 where the Department has established the correct code by rule. For example, the only code that can be used for powered traction therapy is 97012. Regardless of the codes that a provider submits with a decision point or precertification request for these services, the insurer needs only to evaluate the medical necessity of the service.

18.

Yes. The insurer has no obligation to pay for services simply because they were approved in a treatment plan if the NCCI edits prohibit reimbursement for the codes that were billed. The Department has adopted the NCCI edits to prevent duplication of services and unbundling of codes for services that should be included in one treatment session. The NCCI edits apply to services performed by the same provider on the same date of service to the same patient. The NCCI edits are part of the insurer’s obligation to only reimburse for medically necessary treatment. Treatment plan requests typically don’t indicate exactly what services will be performed on any particular day so it is not feasible for the insurer to apply the NCCI edits when reviewing the decision point or precertification request. 

Anyone can obtain the entire current CCI edits from the following web site: www.cms.gov/NationalCorrectCodInitEd/ . Visitors to the site can sort NCCI edits by procedural code or effective date and look for a specific code. There are also links to documents that explain the edits.

19.

As the name states, the Hospital Outpatient Surgical Facility fee schedule in Appendix, Exhibit 7 are the fees for the items listed in N.J.A.C. 11:3-29.5(a)1-8 when provided in connection with a surgical service listed on the schedule. The HOSF fee schedule is not intended to provide fees for all services provided in a hospital outpatient setting. In particular, neither the HOSF nor the ASC fee schedule covers the physician services in the Physicians’ fee column of Exhibit 1. The Department clarified this in the recent amendments to N.J.A.C. 11:3-29.4(a)4, which states, “Except as provided in (a)1 through (3) above, the fees in Appendix, Exhibits 1 through 7 apply regardless of the site of service,” (emphasis added). This includes the codes subject to the Daily Maximum in Exhibit 6.

20.

As stated in N.J.A.C. 11:3-29.4(g), the fee schedules are interpreted in accordance with the Medicare Claims Processing Manual. Chapter 13 of the Medicare Claims Processing Manual, Sections 20.2.1 through 20.2.3 addresses this issue.  If the service is performed on a patient who has been admitted to a hospital outpatient facility for a surgical procedure, the HOSF fee schedule applies. If the patient is referred by a physician simply to have an imaging study performed at the hospital outpatient department, the fees with the TC modifier on the Physicians’ column of Exhibit 1 apply.

21.