Q. Where can I get a copy of the fee schedule rule and the fee schedules?

A. The full text of the current Fee Schedule rule and its six exhibits in both Acrobat and excel file form can be found on the Department's Web site at: http://www.state.nj.us/dobi/aicrapg.htm. 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 Older material can be found located by clicking on the link entitled “Reference/Superceded Material.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

Q. 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 effective dates of the rules?

A. The amendments to the rules are effective for services rendered on or after the effective dates of the rule adoption.

Q. The CPT code for the procedure I performed is not on the fee schedule. What should I bill?

A. The Physicians' fee schedule only includes the most commonly billed codes. The text of the rule at N.J.A.C. 11:3-29.4(e) states that:

(e) The insurer's limit of liability for any medical expense benefit for any service or equipment not set forth in or not covered by the fee schedules shall be a reasonable amount considering the fee schedule amount for similar services or equipment in the region where the service or equipment was provided or, in the case of elective services or equipment provided outside the State, the region in which the insured resides. Where the fee schedule does not contain a reference to similar services or equipment as set forth in the preceding sentence, the insurer's limit of liability for any medical expense benefit for any service or equipment not set forth in the fee schedules shall not exceed the usual, customary and reasonable fee.

Therefore, if a code is not on the fee schedule, the provider should bill his or her usual, reasonable and customary fee.

Q. The CPT code for the service performed has been changed since the fee schedule rule was last amended in 2001. For example, CPT code 20550 was changed in the 2002 edition of the CPT manual to only cover injections to a tendon sheath. Before that, it covered trigger point injections also. Now trigger point injections have their own codes that are not on the fee schedule. How should trigger point injections be billed and paid?

A. 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 whether the service is similar to one already on the fee schedule as required by N.J.A.C. 11:3-29.4(e). That is the standard for determining whether the fee for a CPT code that is on the fee schedule can be used to set a fee for a code that is not on the fee schedule. The answer depends on the circumstances of each case. In the case of the trigger point injections, the AMA thought the services were different enough to create the two new trigger point injection codes (20552 and 20553). On the other hand, CMS considers the three codes (20550, 20552 and 20553) to have very similar Relative Values since the Medicare fees for three codes only differ by a few dollars.

Q. Is the $90.00 a per-provider cap or does it apply to all treatment on that day?

A. The $90.00 is the limit of the insurer's liability for the CPT codes listed in the rule per day. Therefore, it applies regardless of the number of providers that the injured person visits.

Q. Does the multiple procedure reduction formula continue to apply to services subject to the $90.00 daily cap?

A. No, for the CPT codes that are subject to the cap, 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; or

2. the $90.00 daily maximum.

Q. Are medical doctors exempt from the $90.00 daily cap for the Osteopathic Manipulation codes only, or for all Physical Medicine procedures?

A. Medical doctors are exempt from the $90.00 daily cap for the Osteopathic manipulation codes only. The change was made in response to the following comment to the rule:

"A commenter stated that some medical doctors perform manipulative treatments and bill under the same CPT code used by osteopathic physicians."

Q. Does the $90.00 cap apply to CPT 97532 (Cognitive Therapy) and CPT 97750 (Physical Performance Test)?

A. Pursuant to amendments that were effective on April 7, 2003, neither CPT 97532 (Cognitive Therapy) and CPT 97750 (Physical Performance Test) are subject to the $90.00 daily maximum. The CPT codes that are subject to the daily maximum are listed in the Appendix, Exhibit 6 to the rule.

Q. Does the multiple procedures reduction formula apply to diagnostic testing services, such as MRI's or x-rays?

A. No. In 1992, this comment was asked upon amendment to the rule. The Department responded, "No. Nor should the reduction formula be applied to office visit or consultation charges. In all of these instances, standards relating to medical necessity should be applied and reimbursement should be consistent with the definition of "eligible charge at N.J.A.C. 11:3-29.2. For purposes of clarification, the Department has added the word "treatment" to the multiple procedures reference at N.J.A.C. 11:3-29.4(f).

In its amendments to the rule in 2000, the word "treatment" was deleted. The following comment and response was made to that change:

COMMENT: Concerning N.J.A.C. 11:3-29.4(f), many commenters requested
clarification on the deletion of the word "treatment" from the first sentence.
These commenters believe that the elimination of "treatment" could mean that
the daily maximum or multiple procedures reduction formula could be applied to
Evaluation and Management services or diagnostic testing.

RESPONSE: It was not the Department's intent in eliminating the word
"treatment" to make separate and distinct testing procedures subject to the
multiple procedures reduction formula.

Therefore, the multiple procedures reduction formula does not apply to diagnostic testing procedures.

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

A. Yes. It can appear on the bill or list of treatments provided but it cannot be separately reimbursed.

Q. Where a CPT code on the schedule 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?

A. The fee schedule rule follows the practice used by the American Medical Association in developing the CPT system. 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.