N.J. Admin. Code § 10:56-3.1 - Introduction

(a) The New Jersey Medicaid/NJ FamilyCare program utilizes the American Dental Association's Code on Dental Procedures and Nomenclature as published in the Current Dental Terminology (CDT) and incorporated herein by reference, as amended and supplemented, and designated by the Centers for Medicare & Medicaid Services (CMS) as the national standard for reporting dental services under the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191. The CDT is published by, and may be obtained from, the American Dental Association, 211 East Chicago Ave., Chicago, Illinois 60611, http://www.ada.org/ and/or PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010, http://www.medicalcodingbooks.com. Revisions to the CDT (code additions, code deletions and replacement codes) will be reflected in this chapter through publication of a notice of administrative change in the New Jersey Register. Revisions to existing reimbursement amounts specified by the Department and specification of new reimbursement amounts for new codes will be made by rulemaking in accordance with the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq.

(b) The HCPCS codes listed in this subchapter are divided into 11 sections.

Section 3.2-Diagnostic

Section 3.3-Preventive

Section 3.4-Restorative

Section 3.5-Endodontics

Section 3.6-Periodontics

Section 3.7-Prosthodontics, Removable

Section 3.8-Maxillofacial Prosthetics

Section 3.9-Prosthodontics, Fixed

Section 3.10-Oral Surgery

Section 3.11-Orthodontics

Section 3.12-Adjunctive General Services

(c) The basic categories and their assigned code series are as follows:

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(d) Specific elements of the HCPCS which require the attention of the dental provider are as follows:

1. The lists of HCPCS in the 11 separate sections of this subchapter are arranged in tabular form with specific information for a code given under columns with titles such as: "IND," "HCPCS CODES," "MOD," "DESCRIPTION," and "MAXIMUM FEE ALLOWANCE." The information given under each column is summarized below in (d)2 through 6.

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(e) Alphabetic and numeric symbols under "IND" & "MOD" and notes under "DESCRIPTION"

1. These symbols and notes when listed under the "IND", "MOD" and "DESCRIPTION" columns are elements of the HCPCS coding system. They assist the dentist in determining the appropriate procedure codes to be used, the area to be covered, the minimum requirements needed, and any additional parameters required for reimbursement purposes.

2. These symbols and/or letters and/or notes must not be ignored because in certain instances requirements are created in addition to the narrative which accompanies the HCPCS code. THE PROVIDER WILL THEN BE LIABLE FOR THE ADDITIONAL REQUIREMENTS AND NOT JUST THE HCPCS CODE NARRATIVE. These requirements must be fulfilled in order to receive reimbursement.

3. If there is no identifying symbol or note listed, the HCPCS code narrative prevails.

(f) Listed throughout this subchapter are some general and specific policies of New Jersey Medicaid/NJ FamilyCare program relevant to HCPCS. For complete and specific policies in addition to those outlined herein, the practitioner must consult N.J.A.C. 10:56-1 and/or 2.

1. When requesting prior authorization or filing a claim, the HCPCS codes, including the referenced modifiers, must be used in conjunction with the narratives in this subchapter.

2. The use of a procedure code will be interpreted by the New Jersey Medicaid/NJ FamilyCare programs as evidence that the dentist personally furnished, as a minimum, the service for which it stands.

3. For purposes of reimbursement, a dentist, dental group, shared health care facility or dentists sharing a common record shall be considered a single provider.

4. When billing, the provider shall enter into the procedure code column (Item 17B) of the Dental Services Claim Form (MC-10), a HCPCS code as listed in this subchapter. If an appropriate code cannot be found, the provider shall leave the procedure code column blank and shall submit a narrative description of the service for authorization and fee assignment on the Dental Prior Authorization Form MC-10A part 1 of 2 and the Dental Claim Form MC-10 part 2 of 2.

5. Date(s) of service(s) must be indicated on the Dental Services Claim form (MC-10).

6. When submitting a claim, the dentist shall always use her or his usual and customary fee. The fee designated for the HCPCS procedure codes represents the New Jersey Medicaid/NJ FamilyCare fee-for-service programs' maximum reimbursement for the given procedure.

(g) This subsection sets forth an index by dental procedure of codes in this subchapter.

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Notes

N.J. Admin. Code § 10:56-3.1