N.J. Admin. Code § 10:58-3.6 - HCPCS codes qualifiers for certified nurse midwifery services

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

(a) Surgical services: Norplant System (NPS)

11975 WM QUALIFIER: Reimbursed for the insertion and reinsertion of the
Norplant System (six Levonorgestrel Implants) and the
post-insertion visit when provided in a hospital setting, when
the CNM bills for the service. When using this procedure code,
the CNM will not be reimbursed for the cost of the kit. The
supplier of the kit to the CNM will be either reimbursed by
the hospital or be reimbursed directly for the cost of the
kit.
11975 WM 22 QUALIFIER: The maximum fee allowance includes the cost of the
kit supplied to the CNM, the insertion of the Norplant System
(six Levonorgestrel Implants), and the post-insertion visit.
NOTE: The "22" modifier indicates the inclusion of the cost of
the kit.
11976 WM QUALIFIER: The maximum fee allowance is reimbursed for the
removal of the Norplant System (six Levonorgestrel Implants)
and the post-removal visit.
11977 WM QUALIFIER: The maximum fee allowance is reimbursed for the
removal and reinsertion of the Norplant System (six
Levonorgestrel Implants) and the post-removal/reinsertion
visit.
11977 WM 22 QUALIFIER: The maximum fee allowance is reimbursed for the
removal and reinsertion of the "Norplant System" (six
Levonorgestrel Implants) and for the post-removal/reinsertion
visit. NOTE: Modifier "22" indicates that the billing includes
the cost of the NPS kit.
(b) Laboratory services:

36415 QUALIFIER: Once per visit, per patient. Not applicable if
laboratory study, in any part, is performed by the office
staff of the CNM or by CNM herself. When the clinical
laboratory test is performed on site, the venipuncture is not
reimbursable as a separate procedure; its cost is included
within the reimbursement for the laboratory procedure.
(c) Immunization:

W9098 QUALIFIER: This code applies only to high risk beneficiaries
who are 19 years of age.
W9335 QUALIFIER: This code applies only to high risk beneficiaries
who are over 18 years of age.
90741 QUALIFIER: Prior authorization form the Medical Consultant at
the Medicaid District Office is required.
90742 QUALIFIER: Prior authorization from the Medical Consultant at
the Medicaid District Office is required.
(d) Infusion therapy (excluding allergy, immunization and chemotherapy):
90772 SB QUALIFIER: Reimbursement is contingent upon the required
medical necessity, and written chart documentation, including
time and the indication of the CNM's presence with the patient
to the exclusion of her other duties.
90774 SB QUALIFIER: Reimbursement is contingent upon the required
medical necessity, and written chart documentation, including
time and the indication of the CNM's presence with the patient
to the exclusion of her other duties.
90775 SB QUALIFIER: Reimbursement is contingent upon the required
medical necessity, and written chart documentation, including
time and the indication of the CNM's presence with the patient
to the exclusion of her other duties.
90779 SB QUALIFIER: Reimbursement is contingent upon the required
medical necessity, and written chart documentation, including
time and the indication of the CNM's presence with the patient
to the exclusion of her other duties.
(e) Evaluation and management services:

For policy related to qualifiers for the following codes, see 10:58-2.3. (99201WM, 99202WM, 99203WM, 99204WM, 99211WM, 99212WM. 99213WM, 99214WM, 99215WM, 99221WM, 99231WM, 99232WM, 99351WM, 99352WM, 99384WM, 99385WM, 99386WM, 99387WM, 99394WM, 99395WM, 99396WM, 99397WM.)

1. Initial visit codes are as follows:
i. 99201WM, 99202WM

QUALIFIER: An Initial Office Visit is limited to a single visit. Future use of this category of codes will be denied when the beneficiary is seen by the same practitioner, group of practitioners, or member of the same shared health care facility.

ii. QUALIFIER: HCPCS procedure codes 99201WM and 99202WM are exceptions to the requirements outlined in the qualifier for the initial visit. For codes 99201WM and 99202WM, the provider is expected to follow the qualifier applied to routine visit or follow-up care visit for reimbursement purposes.
iii. QUALIFIER: Evaluation and Management services pertain to patients presenting with symptoms, and as such, exclude Preventive Health Care. Preventive services for patients through 20 years of age are billed under EPSDT, when the procedure requirements are met, as described at 10:58-2.3.
2. New patient codes are as follows:
i. 99203WM, 99204WM--Office or other Outpatient services: New Patient.
3. Hospital inpatient services codes are as follows:
i. 99221WM Hospital inpatient services: Initial hospital care; QUALIFIER: When reference is made in the CPT manual to the procedures listed above, the intent of Medicaid/NJ FamilyCare-Plan A fee-for-service is to consider this service as the Initial Visit.
ii. QUALIFIER: Reimbursement for an initial office visit will be disallowed, if a preventive medicine service or EPSDT examination were billed within a twelve month period by a practitioner, group, shared health care facility, or practitioners sharing a common record.
iii. QUALIFIER: In reference to a hospital, the Initial Visit concept will still apply for reimbursement purposes. Subsequent readmissions to the same facility may be reimbursed as Initial Visits, if the readmission occurs more than 30 days from a previous discharge from the same facility by the same provider. When the readmission occurs within 30 days from a previous discharge, the provider shall bill the relevant HCPCS procedure codes specified under the headings Subsequent Hospital Care.
iv. QUALIFIER: Initial hospital visit during a single admission will be disallowed to the same practitioner, group, shared health care facility, or practitioners sharing a common record who submit a claim for a consultation and transfer the patient to their service.
4. Follow-up Visit: Office or other Outpatient services: Established patient codes are: 99212WM, 99213WM, 99214WM.
5. Hospital Inpatient services: Subsequent Hospital care codes are: 99231WM, 99232WM.
6. Home Visit codes are: 99351WM, 99352WM, 99341WM, 99342WM, 99351WM, 99352WM.
i. QUALIFIER: When reference is made in the CPT manual to the services specified above, the intent of Medicaid/NJ FamilyCare-Plan A fee-for-service is to consider this service as the Routine Visit or Follow-Up Care visit. For purposes of Medicaid reimbursement, these codes apply when the provider visits Medicaid /NJ FamilyCare-Plan A fee-for-service beneficiaries in the home setting and the visit does not meet the criteria for a house call.
7. Preventive Medicine Services: Annual Health Maintenance Examination codes are:

New Patient Established Patient
99384 WM 99394 WM
99385 WM 99395 WM
99386 WM 99396 WM
99387 WM 99397 WM
i. QUALIFIER: Preventive medicine services codes (new patient) 99384WM, 99385WM, 99386WM, and 99387WM may only be billed once within 12 months when the beneficiary is seen by the same practitioner, group of practitioners sharing a common record, or member(s) of a shared health care facility. These codes will also be automatically denied for payment when used following an EPSDT examination (procedure code W9820) performed within the preceding 12 months.
ii. Preventive medicine services codes (established patient) 99394WM, 99395WM, 99396WM and 99397WM may be used only once in a 12-month period for any individual over two years of age.
8. Emergency Room Services: CNM's Use of Emergency Room Instead of Office codes are: 99211WM, 99212WM, 99213WM, 99214WM, 99215WM.
i. When a CNM sees her patient in the emergency room instead of his or her office, the CNM shall use the same codes for the visit that would have been used if seen in the CNM's office (99211WM, 99212WM, 99213WM, 99214WM or 99215WM only). Records of that visit should become part of the notes in the office chart.

W9820 WM Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
through age 20.
QUALIFIER: Procedure code W9820 shall be used only once for
the same patient during any 12-month period by the same
practitioner(s) sharing a common record.
QUALIFIER: Reimbursement for code W9820 is contingent upon
the submission of a completed "Report and Claim for
EPSDT/HealthStart Screening and Related Procedures" (MC-19)
form within 30 days of the date of service.
(f) Obstetrical services:

59400 WM Total obstetrical care including antepartum care consisting of
initial antepartum visit and seven subsequent antepartum
visits, vaginal delivery (with or without episiotomy, and/or
forceps) and postpartum care when performed by a certified
nurse midwife. If fewer than eight antepartum visits and one
postpartum visit are provided, this HCPCS code must not be
used for billing purposes. In this situation, each visit must
be billed individually with the appropriate procedure code
designation. Include delivery date on the HCFA 1500 claim form
in Item 24A.

ADDITIONAL VISITS ABOVE SEVEN ANTEPARTUM VISITS--99211WM, 99212WM, 99213WM, 99215WM, 99351WM, 99352WM

NOTE: If medical necessity dictates, corroborated by the record, then additional visits (home or office) above seven antepartum visits may be reimbursed. The claim form should clearly indicate the medical necessity and the date for each office or home visit listed.

59409 WM VAGINAL DELIVERY ONLY, WITH OR WITHOUT EPISIOTOMY AND/OR
FORCEPS BY A CERTIFIED NURSE MIDWIFE
59410 WM REGULAR DELIVERY AND POSTPARTUM VISIT BY A CERTIFIED NURSE
MIDWIFE
This applies to a vaginal delivery (full term or premature,
with or without episiotomy, and/or forceps) and includes one
out-of-hospital visit between the 15th and 60th postpartum day
following delivery. Include delivery date on the claim form in
Item 24A on the HCFA 1500 claim form.
59430 WM Postpartum visit by other than the delivering physician or
delivering certified nurse midwife. One out-of-hospital visit
between the 15th and 60th postpartum day.
W9855 WM Initial Antepartum visit by a Certified Nurse Midwife.
(Separate procedure.)
W9856 WM Subsequent Antepartum Visit by a Certified Nurse Midwife.
(Separate procedure.) Indicate the specific dates of service
on the HCFA 1500 claim form on Item 24.
(g) HealthStart Maternity Medical Care Services codes are as follows:

W9025 WM HealthStart INITIAL ANTEPARTUM MATERNITY MEDICAL CARE VISIT
BY CERTIFIED NURSE MIDWIFE
HealthStart INITIAL ANTEPARTUM MATERNITY MEDICAL CARE VISIT
BY CERTIFIED NURSE MIDWIFE includes:
1. History, including system review
2. Complete physical examination
3. Risk assessment
4. Initial care plan
5. Patient counseling and treatment
6. Routine and special laboratory tests on site, or by
referral, as appropriate
7. Referral for other medical consultations, as appropriate
(including dental)
8. Coordination with the HealthStart Health Support Services
provider, as applicable.
W9026 WM HealthStart SUBSEQUENT ANTEPARTUM MATERNITY MEDICAL CARE
VISIT BY CERTIFIED NURSE MIDWIFE
HealthStart SUBSEQUENT ANTEPARTUM MATERNITY MEDICAL CARE
VISIT BY CERTIFIED NURSE MIDWIFE includes:
1. Interim history
2. Physical examination
3. Risk assessment
4. Review of plan of care
5. Patient counseling and treatment
6. Laboratory services on site or by referral, as appropriate
7. Referrals for other medical consultations, as appropriate
8. Coordination with HealthStart case coordinator.
NOTE: This code may be billed only for the second through 15th
antepartum visit.
NOTE: If medical necessity dictates, corroborated by the
record, additional visits above the 15th visit may be
reimbursed under procedure code for routine or follow-up
visit--midwife, that is, OFFICE: 99211WM, 99212WM, 99213WM,
99214WM, 99215WM, or HOME: 99351WM, 99352WM. The date and
place of service shall be included on each claim detail line
on the HCFA 1500 claim form. The claim form should clearly
indicate the reason for the medical necessity and date for
each additional visit.
W9027 HealthStart REGULAR DELIVERY BY CERTIFIED NURSE MIDWIFE
HealthStart REGULAR DELIVERY BY CERTIFIED NURSE MIDWIFE
includes:
1. Admission history
2. Complete physical examination
3. Vaginal delivery with or without episiotomy and/or forceps
4. Inpatient postpartum care
5. Referral to postpartum follow-up care provider including:
i. Mother's hospital discharge summary and
ii. Infant's discharge summary, as appropriate
NOTE: Obstetrical delivery applies to a full term or premature
vaginal delivery and includes care in the home, birthing
center or in the hospital (inpatient setting). Include the
delivery date on the HCFA 1500 claim form in Item 24A.
W9028 WM HealthStart POSTPARTUM CARE VISIT BY CERTIFIED NURSE MIDWIFE
HealthStart POSTPARTUM CARE VISIT BY CERTIFIED NURSE MIDWIFE
includes:
1. Outpatient postpartum care by the 60th day after the
vaginal or caesarean section delivery
i. Review of prenatal, labor and delivery course;
ii. Interim history, including information on feeding and
care of the newborn;
iii. Physical examination;
iv. Referral for laboratory services, as appropriate;
v. Referral for ongoing medical care when appropriate;
vi. Patient counseling and treatment;
NOTE: The postpartum visit shall be made by the 60th
postpartum day. Include the delivery date on the HCFA 1500
claim form in Item 24A.
W9029 WM HealthStart REGULAR DELIVERY AND POSTPARTUM BY CERTIFIED NURSE
MIDWIFE
HealthStart REGULAR DELIVERY AND POSTPARTUM BY CERTIFIED NURSE
MIDWIFE includes:
1. Admission history
2. Complete physical examination
3. Vaginal delivery with or without episiotomy and/or forceps
4. Inpatient postpartum care
5. Referral to postpartum follow-up care provider including:
i. Mother's hospital discharge summary;
ii. Infant's discharge summary, as appropriate.
6. Outpatient postpartum care by the 60th day after the
delivery
i. Review of prenatal, labor and delivery course;
ii. Interim history, including information on feeding and
care of the newborn;
iii. Physical examination;
iv. Referral for laboratory services, as appropriate;
v. Referral for ongoing medical care when appropriate;
vi. Patient counseling and treatment.
NOTE: This code applies to a full term or premature vaginal
delivery and includes care in the home, birthing center or in
the hospital (inpatient setting). Include delivery date on the
HCFA 1500 claim form in Item 24A.
W9030 WM HealthStart TOTAL OBSTETRICAL CARE BY CERTIFIED NURSE MIDWIFE
Total obstetrical care consists of:
1. INITIAL ANTEPARTUM VISIT AND FOURTEEN SUBSEQUENT ANTEPARTUM
VISITS BY THE CERTIFIED NURSE MIDWIFE. Specific dates are to
be listed on the claim form.
NOTE: Reimbursement will be denied if the services delivered
do not meet the criteria for the visits. The elements of the
visits shall include the following:
i. History (initial or review), including system review;
ii. Complete physical examination;
iii. Risk assessment;
iv. Initial and ongoing care plan;
v. Patient counseling and treatment;
vi. Routine and special laboratory tests on site, or by
referral, as appropriate;
vii. Referral for other medical consultations, as
appropriate (including dental);
viii. Coordination with the HealthStart Health Support
Services provider, as applicable.
2. REGULAR VAGINAL DELIVERY BY CERTIFIED NURSE MIDWIFE:
The elements of the care shall include the following:
i. Admission history;
ii. Complete physical examination;
iii. Vaginal delivery with or without episiotomy and/or
forceps;
iv. Inpatient postpartum care.
NOTE: Include the delivery date on the HCFA 1500 claim form
in Item 24.
3. POSTPARTUM CARE VISIT BY CERTIFIED NURSE MIDWIFE:
Outpatient postpartum care by the 60th day after the vaginal
delivery (full term of premature):
i. Review of prenatal, labor and delivery course;
Interim history, including information on feeding and care of
the newborn;
Physical examination;
iv. Referral for laboratory services, as appropriate;
v. Referral for ongoing medical care when appropriate;
vi. Patient counseling and treatment.

Notes

N.J. Admin. Code § 10:58-3.6
Amended by R.2001 d.204, effective 6/18/2001.
See: 33 N.J.R. 1160(a), 33 N.J.R. 2188(a).
Rewrote (c) and (e).
Amended by R.2006 d.338, effective 9/18/2006.
See: 38 N.J.R. 2003(a), 38 N.J.R. 3900(a).
In (d), updated table.

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