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 seven exhibits in both Acrobat and MS Excel file form can be found on the Department’s web site at: www.state.nj.us/dobi/pipinfo/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 Older material can be found located by clicking on the link entitled “Reference/Superceded Material."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.  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).

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:

(e)   Except as noted in (e)1 and 2 below, 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.

1. For the purposes of this subchapter, determination of the usual, reasonable and customary fee means that the provider submits to the insurer his or her usual and customary fee. The insurer determines the reasonableness of the provider’s fee by comparison of its experience with that provider and with other providers in the region. The insurer may use national databases of fees, such as those published by Ingenix (www.ingenixonline.com) or Wasserman (www.medfees.com), for example, to determine the reasonableness of fees for the provider’s geographic region or zip code.
   
   

2. All applicable provisions of this section concerning billing and payment apply to fees for services provided outside of New Jersey and to fees that are not on the fee schedule.

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.

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.

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.

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:

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

2. the $99.00 daily maximum.

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).

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.

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

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. 

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.

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:

11:3-29.4(g) 6 - CPT code 99145 is incorrect. The correct fee is 99150. The section should read as follows: “CPT codes 99148 through 99150 are only reimburseable when a second physician other than the provider performing the diagnostic or therapeutic services provides moderate sedation in a facility setting (for example, hospital, outpatient hospital/ambulatory surgery center or skilled nursing facility). CPT codes 99148 through 99145 99150 are not reimburseable for services performed by a second physician in a physician office, freestanding imaging center or for any procedure code identified in CPT as including moderate (conscious) sedation.”

In Exhibit I, the Physicians’ Fee Schedule: