N.J. Admin. Code § 10:53A-4.3 - Basis of payment-physician services

Current through Register Vol. 54, No. 7, April 4, 2022

(a) The method of calculation of the basic per diem rates for hospice services listed in 10:53A-4.1 includes the costs of the administrative and general supervisory activities performed by physicians who are employees of the hospice provider or those working under financial arrangements with the hospice provider.
1. The administrative and supervisory activities are generally performed by the physician serving as the Medical Director and/or the physician member of the hospice interdisciplinary group.
i. Interdisciplinary group activities include participation in the establishment of plans of care, supervision of care and services, periodic review and updating of plans of care, and the establishment of governing policies.
(b) The Division shall pay the physician for only direct patient care services furnished to Medicaid/NJ FamilyCare FFS hospice beneficiaries by hospice physician employees, and for physician services furnished under arrangements made by the hospice, unless the services were provided on a volunteer basis. The cost of the direct patient care services of the physician who is employed by or under contract with the hospice agency shall be submitted on the CMS 1500 claim by the physician to the fiscal agent.
1. Physician services furnished on a volunteer basis are excluded from Medicaid/NJ FamilyCare FFS reimbursement.
2. The physician may bill for services which are not provided on a volunteer basis. However, the physician shall treat Medicaid and NJ FamilyCare FFS beneficiaries on the same basis as other beneficiaries in the hospice. For instance, a physician may not designate all physician services rendered to non-Medicaid patients as volunteered and at the same time seek payment from the hospice for all physician services rendered to Medicaid and NJ FamilyCare FFS beneficiaries.
(c) The attending physician shall bill only for direct personal care services and not for other costs such as laboratory or X-rays, which are to be included in the hospice per diem rate.
1. The costs of attending physician's direct personal care services shall not be included in the hospice cap determinations.
(d) Attending physician services and other specialty physician services, including consultation services provided by physicians who are not employees of the hospice, are reimbursed as covered services on a fee-for-service basis under N.J.A.C. 10:54, Physician Services, separate from the method of calculation of the hospice per diem rates listed in 10:53A-4.2.
1. The hospice shall state the name of the physician who has been designated the attending physician (whenever the attending physician is not a hospice employee) in the plan of care and on the Election of Hospice Benefits Statement, FD-378; and specify whether the attending physician services are either related or unrelated to the beneficiary's terminal illness.


N.J. Admin. Code § 10:53A-4.3
Amended by R.1997 d.479, effective 11/17/1997.
See: 29 N.J.R. 3441(a), 29 N.J.R. 4853(a).
Amended by R.2003 d.320, effective 8/4/2003.
See: 34 N.J.R. 2899(a), 35 N.J.R. 3568(a).
Rewrote the section.
Amended by R.2008 d.226, effective 8/4/2008.
See: 40 N.J.R. 1582(a), 40 N.J.R. 4578(a).
In the introductory paragraph of (b), substituted "CMS" for "HCFA"; and in (d)1, deleted "(2/02)" following "FD-378".

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