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| Auto Medical Fee Schedule Frequently Asked Questions | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 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. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Q. Where can I get a copy of the fee schedule rule and the fee schedules? 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 |
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| 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 normal procedure is for amendments to the rules to be effective for services rendered on or after the effective dates of the rule adoption. For the changes to the fee schedule rule that were adopted by the Department on 10/7/09 but were stayed by the Appellate Division pending an appeal, the new fee schedules are effective for treatment on or after 8/10/09, the date of the Appellate Division decision. |
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Q. Under the old Fee Schedule, we were in the Central Region. Now the Fee Schedule has North and South Regions. What region am I in? A. The list of zip codes comprising the North and South Regions and a lot of other important information about how the Fee Schedules are to be used are in the text of the Fee Schedule Rule - PDF or MS Word (Effective for treatment rendered on or after 8/10/09). |
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Q. The CPT code for the procedure I performed is not on the fee schedule. What should I bill? A. The recent amendments to the Physicians’ fee schedule include around 1,000 procedures. However, there will be some procedures that are not included. The text of the rule at N.J.A.C. 11:3-29.4(e) states that:
The recent Appellate Division decision, August 10, 2009, Docket number A-0344-07T3, stated that for determinations of UCR for treatment rendered August 10 and after, the Ingenix database should not be used as one of the national databases mentioned in the rule for determining UCR until the Department reviews it. The Department notes that the Appellate Division decision does not affect any determinations of UCR for treatments rendered prior to August 10, 2009. |
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Q. The CPT code for the service performed has been changed since the fee schedule rule was last amended. 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. |
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Q. Is the $99.00 a per-provider cap or does it apply to all treatment on that day? A. The $99.00 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. |
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Q. Does the multiple procedure reduction formula continue to apply to services subject to the $99.00 daily cap? A. No, for the CPT codes that are subject to the daily maximum, the insurer’s limit of liability is the lesser of:
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Q. Does the multiple procedures reduction formula apply to diagnostic testing services, such as MRI’s or x-rays? A. No. The multiple procedures reduction formula applies only to multiple and bilateral surgeries (CPT 10000 through 69999). The rules concerning multiple and bilateral procedures and assistant and co-surgeons have been extensively redrafted in the recent adoption to the rule. See N.J.A.C. 11:3-29.4(f). |
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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. |
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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. |
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Q. What does the ANES code on the Physicians’ Fee Schedule mean? A. The amounts listed under the ANES code on the Physicians’ Fee Schedule is the conversion factor for anesthesia units. Payors should follow Medicare guidelines for the number of units for the various CPT codes for the administration of anesthesia and other billing practices. These can be found at: www.cms.hhs.gov/center/anesth.asp |
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Q. The modifier –TS is already used to in Medicare for follow up care. Should this modifier still be used for service provided in trauma units? A. Unfortunately, the Department was not notified of this before the rule was adopted and it can only be changed by proposing an amendment to the rule. However, the Department does not believe that the - TS modifier is commonly used for follow up care in PIP claims. Payors and vendors will have to modify their systems to use the –TS code for reporting trauma care. |
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Q. There are no CPT codes on the Physicians’ Fee Schedule that are in Grouper 6, 7 or 8 of the Ambulatory Surgical Center (ASC) Fee Schedule. A. The Department used the CPT codes that had ASC Groupers in the Medicare Physicians’ Fee Schedule that was in effect when the rule was drafted. None of the CPT codes on the PIP fee schedule were in the 6, 7 or 8 Medicare Groupers. Here is a list of all the Medicare CPT codes that had ASC groupers before the ASC payment methodology was changed. This may be helpful for identifying related groupers for codes on the Fee Schedule that do not have groupers or for codes that are not on the Fee Schedule. |
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Q. I believe there is an error on the fee schedule. A. Since issuance of the Appellate Division decision, the Department has received information from the regulated community regarding a number of nonsubstantive errors on the Physicians’ Fee Schedule and certain changes in CPT coding. The correct information is set out below. In the near future, the Department will propose amendments to the fee schedule rule to conform the entries on the schedule to the revisions noted below. In the text of the rule: In Exhibit I, the Physicians’ Fee Schedule: |
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| Updated: October 6, 2009 |
| OPRA is a state law that was enacted to give the public greater access to government records maintained by public agencies in New Jersey. | You will need to download the latest version of Adobe Acrobat Reader in order to correctly view and print PDF (Portable Document Format) files from this web site. | |||
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State of New Jersey New Jersey Department of Banking and Insurance |
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