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Home > PIP Information for Health Care Providers > Auto Medical Fee Schedule Frequently Asked Questions
Auto Medical Fee Schedule Frequently Asked Questions
(for rule effective January 4, 2013)
Updated 01/27/14

Disclaimer: This document is a compilation of the most frequently asked questions (FAQ) concerning the Personal Injury Protection ("PIP") Medical Fee Schedule, which is published in the New Jersey Register at N.J.A.C. 11:3-29. The purpose of this document is to respond to questions of general application raised by providers and payers. Information in this FAQ is not intended to replace the provisions of the rule, which govern. The information in this FAQ may be updated, corrected or deleted at any time without notice.

Please note that the Department does not interpret its rules in response to questions. Neither does it perform legal research, provide legal advice or issue advisory opinions to members of the public or other entities. The Department believes that the text of the statutes and rules, the responses to comments on adoption and the Bulletins and Orders issued by the Department, all of which are on our website (www.state.nj.us/dobi/pipinfo/aicrapg.htm), contain the necessary information.

 
Frequently Asked Questions
1. Where can I get a copy of the fee schedule rule and the fee schedules? Answer
2. Are the changes made by adopted amendments to the fee schedule rule effective as of the date services were provided or for bills processed on or after the operative dates of the rules? Answer
3. What region am I in? Answer
4. The CPT or HCPCS code for the service I want to provide is not on the Physicians' fee column of Appendix, Exhibit 1. What should I bill? Answer
5. The CPT or HCPCS code for the service I want to perform is listed in Exhibit 1 but there is no fee in the Physicians' Fee column. Does this mean that the service is not reimbursable? Answer
6. There is no fee in the ASC facility fee column of Appendix, Exhibit 1 for the service I want to provide in an ASC. Answer
7. The CPT code for the service I want to perform in an ASC has been changed since the fee schedule rule was adopted. Are the insurance companies correct in saying that if I bill the new code, the ASC facility fee for the service is not reimburseable because that code is not on the ASC fee column of Exhibit 1? Answer
8. There is no facility fee in the HOSF fee schedule for the service I want to perform in an HOSF. Answer
9. The CPT code for the service to be performed has been changed since the fee schedule rule was last amended. Answer
10. Is the $105.00 a per-provider cap or does it apply to all treatment on that day? Answer
11. Does the multiple procedure reduction formula found in the rule text at N.J.A.C. 11:3-29.4(f) apply to services subject to the $105.00 daily maximum? Answer
12. Does the multiple procedures reduction formula apply to Physicians’ fees for diagnostic testing services, such as MRIs or x-rays? Answer
13. Can the administration of hot/cold packs (CPT 97010) be shown on the bill for services even though it is not reimbursable? Answer
14. Where a CPT code on the Physicians’ fee column of Appendix, Exhibit 1 is listed twice, once with no modifier and once with a modifier -26, should a provider who performs both the technical and professional part of the service receive the sum of the two fees or only the unmodified (global) fee? Answer
15. What does the ANES code on the Physicians’ Fee Schedule mean? Answer
16. Do the provisions in N.J.A.C. 11:3-29.4(f) (multiple and bilateral surgeries, co-surgeries and assistant surgeons) apply to facility fees billed by ASCs and HOSFs pursuant to N.J.A.C. 11:3-29.5(d)? Answer
17. In N.J.A.C. 11:3-29.4(k), the Department encourages providers to submit the medical necessity and justification for the use of unlisted codes (XXX99) as part of decision point or precertification requests. If an unlisted CPT code is submitted and approved during a decision point or precertification request for services, the service is provided and when the bill is submitted, the insurer determines that there is a more appropriate CPT code for the service, is the insurer still able to assign the appropriate CPT code? Answer
18. I got a list of CPT codes precertified as part of a treatment plan but when I billed for the treatments performed, the carrier applied the National Correct Coding Initiative (NCCI) edits and denied payment for some of the codes. Is this allowed? Answer
19. A Kessler Rehab facility bill meets the definition of a "Hospital Outpatient” services. Does that mean that the HOSF rate would apply to any and all services being performed in this facility? If Physical Therapy is performed on an outpatient basis at Kessler Rehab, do the fees for these services on the Physicians’ Fee Schedule and the Daily maximum apply or should the insurer apply UCR? Answer
20. Certain services such as X-rays and MRIs have fees both on the Physicians’ fee schedule and the Hospital Outpatient Surgical Facility fee schedule. When is it appropriate to apply the HOSF fee (Exhibit 7) versus the Technical component of the Physicians’ fee column of Exhibit 1? Answer
21. Who bills for CPT 99281 through 99285 (emergency room visit) and how should such bills be paid? Answer
 
1. Where can I get a copy of the fee schedule rule and the fee schedules?


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

 
2. Are the changes made by adopted amendments to the fee schedule rule effective as of the date services were provided on or for bills processed on or after the operative dates of the rules?

The fee schedule rules adopted on November 5, 2012 will be effective for services rendered on or after January 4, 2013.
 
3. What region am I in?


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)

 
4. The CPT or HCPCS code for the service I want to provide is not on the Physicians' fee column of Appendix, Exhibit 1. What should I bill?


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.

 
5. The CPT or HCPCS code for the service I want to perform is listed in Exhibit 1 but there is no fee in the Physicians' Fee column. Does this mean that the service is not reimbursable?

No. There are certain CPT/HCPCS codes for which there is a fee in the ASC fee column of Exhibit 1 but for which the Department has not established a physician fee. 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.
 
6. There is no fee in the ASC facility fee column of Appendix, Exhibit 1 for the service I want to provide in an ASC.

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, certain codes that do not have fees in the ASC facility fee column have “N1” in the payment indicator column. 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.

 
7. The CPT code for the service I want to perform in an ASC has been changed since the fee schedule rule was adopted. Are the insurance companies correct in saying that if I bill the new code, the ASC facility fee for the service is not reimbursable because that code is not on the ASC fee column of Exhibit 1?

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:

New Code Old Code
64635 64622
64636 64623
64633 64626
64634 64627
 
8. There is no facility fee in the HOSF fee schedule for the service I want to perform in an HOSF.


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).

 
9. The CPT code for the service to be performed has been changed since the fee schedule rule was last amended.


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).

 
10. Is the $105.00 a per-provider cap or does it apply to all treatment on that day?


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.

 
11. Does the multiple procedure reduction formula found in the rule text at N.J.A.C. 11:3-29.4(f) apply to services subject to the $105.00 daily maximum?


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.

 
12. Does the multiple procedures reduction formula apply to Physicians’ fees for diagnostic testing services, such as MRIs or x-rays?


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.

Can the administration of hot/cold packs (CPT 97010) be shown on the bill for services even though it is not reimbursable?

Yes. It can appear on the bill or list of treatments provided but it cannot be separately reimbursed pursuant to the text of the rule at N.J.A.C. 11:3-29.4(g)1.
 
14. Where a CPT code on the Physicians’ fee column of Appendix, Exhibit 1 is listed twice, once with no modifier and once with a modifier -26, should a provider who performs both the technical and professional part of the service receive the sum of the two fees or only the unmodified (global) fee?


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.

 
15. What does the ANES code on the Physicians’ Fee Schedule mean?


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).

 
16. Do the provisions in N.J.A.C. 11:3-29.4(f) (multiple and bilateral surgeries, co-surgeries and assistant surgeons) apply to facility fees billed by ASCs and HOSFs pursuant to N.J.A.C. 11:3-29.5(d)?


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).

 
17. In N.J.A.C. 11:3-29.4(k), the Department encourages providers to submit the medical necessity and justification for the use of unlisted codes (XXX99) as part of decision point or precertification requests. If an unlisted CPT code is submitted and approved during a decision point or precertification request for services, the service is provided and when the bill is submitted, the insurer determines that there is a more appropriate CPT code for the service, is the insurer still able to assign the appropriate CPT code?


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.

I got a list of CPT codes precertified as part of a treatment plan but when I billed for the treatments performed, the carrier applied the National Correct Coding Initiative (NCCI) edits and denied payment for some of the codes. Is this allowed?


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.

A Kessler Rehab facility bill meets the definition of a "Hospital Outpatient” services. Does that mean that the HOSF rate would apply to any and all services being performed in this facility? If Physical Therapy is performed on an outpatient basis at Kessler Rehab, do the fees for these services on the Physicians’ Fee Schedule and the Daily maximum apply or should the insurer apply UCR? 


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.

Certain services such as X-rays and MRIs have fees both on the Physicians’ fee schedule and the Hospital Outpatient Surgical Facility fee schedule. When is it appropriate to apply the HOSF fee (Exhibit 7) versus the Technical component of the Physicians’ fee column of Exhibit 1?

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.

Who bills for CPT 99281 through 99285 (emergency room visit) and how should such bills be paid?

For a single patient encounter in the ER, a carrier can receive bills that include 9928X from two types of providers:

The ER physician bills on a HCFA 1500 form for the evaluation and management of the emergency room patient. Such bills would be reimbursed according to the Physicians' Fee column in Exhibit 1 unless the service qualifies, and is identified on the bill, for the trauma exemption in N.J.A.C. 11:3-29.4(a)1.

The hospital may also bill CPT 9928X for the non-physician service, such as use of the emergency room, in addition to supplies, etc. on a UB04 form. Such bills would be reimbursed at the usual, customary and reasonable amount as provided in N.J.A.C. 11:3-29.4(e).
 
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