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1 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL


N.J.A.C. 10:62 (2014)
Title 10, Chapter 62 -- Chapter Notes
CHAPTER AUTHORITY:

N.J.S.A. 30:4D-1 et seq. and 30:4J-8 et seq.



2 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.1 (2014)
§ 10:62-1.1 Scope

This subchapter delineates the New Jersey Medicaid and NJ FamilyCare fee-for-service program standards for examinations and care for vision defects and/or eye diseases for the purpose of maintaining or improving the health of New Jersey Medicaid and NJ FamilyCare fee-for-service beneficiaries.


3 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.2 (2014)
§ 10:62-1.2 Definitions
The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise:

"Ophthalmologist" means a fully licensed medical doctor who has been recognized by the New Jersey Medicaid or NJ FamilyCare fee-for-service program as a specialist in ophthalmology.

"Optometrist" means any person who is licensed by the New Jersey State Board of Optometry to engage in the practice of optometry, or licensed to engage in the practice of optometry in the state in which he or she performs such functions.

"Practitioner" means a licensed ophthalmologist or optometrist, acting within the scope of licensure.

"Transfer" means the relinquishing of responsibility for the continuing care of the beneficiary by one practitioner and the assumption of such responsibility by another practitioner.


4 of 41 DOCUMENTS

NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law

*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.3 (2014)
§ 10:62-1.3 Providers of professional services
(a) Within the restrictions of their respective licensure, the following are eligible providers of eye care upon fulfilling the Enrollment Process requirements in N.J.A.C. 10:49-3.2:

1. Ophthalmologists or optometrists licensed in the State of New Jersey;

2. Ophthalmologists or optometrists in another state who are duly licensed in that state;

3. Independent clinics approved by the New Jersey Medicaid or NJ FamilyCare fee-for-service program to render eye care services; and

4. Hospitals meeting the definition of "approved hospital" as described in N.J.A.C. 10:52-1.1 of the Hospital Services Manual.


5 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES

N.J.A.C. 10:62-1.4 (2014)

§ 10:62-1.4 Covered services
Professional services include office visits for evaluation and management, comprehensive eye examinations, low vision examinations, low vision work-ups, vision training work-ups, vision training program visits as well as other specific procedures as listed at N.J.A.C. 10:62-3.2. Payment is made subject to the limitations specified under each type of service. If a service requires prior authorization, see N.J.A.C. 10:62-1.16.


6 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.5 (2014)
§ 10:62-1.5 Comprehensive eye examination

(a) A comprehensive eye examination may include cycloplegics and a post cycloplegic visit. All findings and data, including positive and negative, shall be clearly recorded. A comprehensive eye examination shall include the following, as a minimum, where possible unless contraindicated:

1. Detailed case history;

2. Complete visual acuity findings;

3. External and internal (ophthalmoscopic) examination including slit lamp;

4. Refraction (objective and subjective);

5. Extra-ocular measurement (EOM);

6. Gross visual fields (central and peripheral);

7. Tonometry (when indicated for patients under 35; mandatory for all patients over 35). The specific method used should be identified and recorded (the finger palpation test is not acceptable);

8. Binocular coordination testing (distance and near), fusion, steropsis, and color vision;

9. The diagnosis (ocular deficiency or deformity, visual or muscular anomaly, and so forth); and

10. Recommendations.

(b) For reimbursement purposes, a comprehensive eye examination shall include all the criteria of a comprehensive eye examination plus complete Diagnostic Visual Fields.

1. Comprehensive eye examinations with diagnostic fields are not routinely reimbursable for complete comprehensive eye examination. Patients should be selected for this additional service based upon history and ophthalmologic findings during the examination if the physical examination suggests the presence of optic or motor nerve abnormalities, or if other significant physical findings are present and documented, diagnostic visual field studies may be selectively employed to establish or to confirm the diagnosis and/or the degree of impairment.

2. A comprehensive eye examination with or without diagnostic fields shall be limited to once a year.


7 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.6 (2014)
§ 10:62-1.6 Low vision examination
(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Plan C service are set forth at N.J.A.C. 10:49-9.

(b) Personal contribution to care for NJ FamilyCare-Plan C services is $ 5.00 a visit for office visits, except when the service is provided for preventive care.

1. An office visit is defined as a face-to-face contact with a vision care professional, which meets the documentation requirements in this subchapter and N.J.A.C. 10:62-4.

2. Office visits include eye care professional services provided in the office, patient's home, or any other site, excluding hospital, where the child may have been examined by the vision care professional. Generally, these procedure codes are set forth in N.J.A.C. 10:62-3.2 and 3.3.

(c) Vision care professionals shall not charge a personal contribution to care provided to newborns, who are covered under fee-for-service for Plan C; or for preventive services.

8 of 41 DOCUMENTS

NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.7 (2014)
§ 10:62-1.7 Low vision work-up
A low vision work-up as defined in N.J.A.C. 10:62-3.3 requires prior authorization (see N.J.A.C. 10:62-1.16). For purposes of the New Jersey Medicaid and NJ FamilyCare fee-for-service programs, a low vision work-up consists of certain testing techniques and procedures to determine what optical aids and devices can be prescribed for an individual to increase range of vision. A low vision work-up requires a written report and is much more detailed than the low vision examination that follows a complete comprehensive examination.


9 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.8 (2014)

§ 10:62-1.8 Vision training program
(a) Vision training requires prior authorization (see N.J.A.C. 10:62-1.16). For purposes of the New Jersey Medicaid and NJ FamilyCare fee-for-service programs, vision training is the use of certain procedures and modalities for the development of and/or increase in the vision capacity of the eye(s) with poor and/or inconsistent or distorted vision localization.

(b) Vision training is limited to orthoptics, with its acceptable procedures and/or modalities, and further limited to the following types of conditions to be treated by private physicians approved for such training by the respective peer group:

1. Strabismus;

2. Amblyopia;

3. Heterophoria; and

4. Accommodative and/or convergence anomalies.

(c) If vision training is required following the initial comprehensive eye examination, the practitioner shall submit a written request (form FD-358) to the Vision Care Unit for prior authorization (see N.J.A.C. 10:62-1.16) for a vision training work-up. This request shall include the preliminary findings, detailed reason(s) why it is believed a further evaluation is needed, and any history of previous vision training with the dates and the results. Upon receiving approval for a vision training work-up, the practitioner shall then submit, within 30 days of receipt of authorization, the work-up report to the Vision Care Unit. The vision training work-up report shall consist of, but not be limited to:

1. Diagnosis;

2. Findings;

3. Interpretation;

4. Recommendations;

5. Outline of training procedures and frequency of sessions with estimated duration of treatment; and

6. Prognosis.

(d) The decision of the Vision Care Unit to approve or deny vision training will be transmitted to the practitioner by the fiscal agent.

(e) Upon completion of an approved training program, the practitioner shall submit a detailed progress report, listing the status of all parameters indicated in the original evaluation. No treatment plan shall exceed a period of 90 days or a total of 30 training visits, commencing with the inception of the treatment plan. An additional prior authorization is required for any extension of treatment and requires submission of a detailed progress report to the Vision Care Unit.

(f) Vision training may be provided by a practitioner when found medically necessary. This service can be performed in the office or in an independent clinic approved by the New Jersey Medicaid or NJ FamilyCare fee-for-service program.


10 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.9 (2014)
§ 10:62-1.9 New patient office visits
(a) HCPCS 99201, 99202, 99203, 99204, 99205, 99301, 99302, 99303, 99321, 99322 and 99323 are not reimbursable with 92002, 92004, 92012 or 92014 on the same day.

(b) When the setting for the initial visit is an office or residential health care facility, for reimbursement purposes it is limited to a single visit. Future use of this category of codes shall be denied when the beneficiary is seen by the same physician, group of physicians, or shared health care facility. (See N.J.A.C. 10:49-4 for definition of shared health care facility.)

(c) Reimbursement for an initial office visit also precludes subsequent reimbursement for an initial residential health care facility visit and vice versa.

(d) When multiple special ophthalmological services or ophthalmoscopic services are billed on the same day for the same patient in an office setting, reimbursement shall be limited to the highest valued procedure.



11 of 41 DOCUMENTS

NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law

*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.10 (2014)
§ 10:62-1.10 Established patient office visits
(a) Codes 99201, 99202, 99203, 99204, 99205, 99301, 99302, 99303, 99321, 99322 and 99323 are not reimbursable with 92002, 92004, 92012 or 92014 on the same day.

(b) When multiple special ophthalmological services or ophthalmoscopic services are billed on the same day for the same patient in an office setting, reimbursement shall be limited to the highest valued procedure.



12 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.11 (2014)
§ 10:62-1.11 Emergency room visits

(a) When a physician sees the patient in the emergency room instead of the practitioner's office, the physician shall use the same HCPCS for the visit that would have been used if seen in the physician's office (99211, 99212, 99213, 99214 or 99215 only). Records of that visit shall become part of the notes in the office chart.

(b) When patients are seen by hospital-based emergency room physicians who are eligible to bill the Medicaid or NJ FamilyCare fee-for-service program, then the appropriate HCPCS shall be used. The "Visit" codes are limited to 99281, 99282, 99283, 99284 and 99285.


13 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.12 (2014)
§ 10:62-1.12 Inpatient hospital services

(a) To qualify as documentation that the service was rendered by the practitioner during an inpatient stay, the beneficiary's medical record must contain the practitioner's notes indicating that the practitioner personally:

1. Reviewed the beneficiary's medical history with the beneficiary and/or his or her family, depending upon the medical situation;

2. Performed an eye examination, or other procedure;

3. Established, confirmed or revised the diagnosis; and

4. Visited and examined the beneficiary on the day(s) for which a claim for reimbursement is made.

(b) An initial hospital visit during a single admission shall be disallowed to the same physician, 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.

(c) When performing corneal tissue transplant surgery, providers shall request and receive prior authorization for HCPCS V2785 (processing, preserving and transplanting corneal tissue). Ophthalmologists shall submit the completed "Request for Prior Authorization of Optical Appliances" to Division staff with the provider's laboratory invoice attached to the request.

1. Ophthalmologists shall not bill for V2785 when the procedure is performed in a hospital.


14 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.13 (2014)
§ 10:62-1.13 Consultations

(a) A consultation shall be recognized for reimbursement only when performed by a specialist recognized as such by the Medicaid or NJ FamilyCare program and the request has been made by or through the patient's attending physician and the need for such a request would be consistent with good medical practice. Two types of consultation shall be recognized for reimbursement: comprehensive consultation and limited consultation.

(b) In order to receive reimbursement for the HCPCS for an office consultation (99244, 99245) or a confirmatory consultation (99274 and 99275), the provider shall perform a total systems evaluation by history and physical examination, including a total systems review and total systems physical examination, or, alternatively, utilize one or more hours of the consulting physician's personal time in the performance of the consultation.

(c) In addition to the recordkeeping requirements of N.J.A.C. 10:62-1.20, reimbursement for HCPCS 99244, 99245, 99274 and 99275 (Comprehensive consultation) requires the following applicable statements, or language essentially similar to those statements, to be inserted in the "remarks" section of the claim form. The claim form shall be signed by the provider who performed the consultation.

1. Examples:

i. I personally performed a total (all) systems evaluation by history and physical examination; or

ii. This consultation utilized 60 or more minutes of my personal time.

(d) The following regarding consultations shall also apply:

1. If a consultation is performed in an inpatient or outpatient setting and the patient is then transferred to the consultant's service during that course of illness, then the provider shall not bill for an Initial Visit if the practitioner billed for the consultation.

2. If there is no referring physician, then an Initial Visit HCPCS shall be used instead of a consultation HCPCS.

3. If the patient is seen for the same illness on repeated visits by the same consultant, such visits are considered routine visits or follow-up care visits, and not consultations.

4. Consultation HCPCSs shall be denied in an office or residential health care facility setting if the consultation has been requested by or between members of the same group, shared health care facility or physicians sharing common records. A Routine Visit code is applicable under these circumstances.

5. If a prior claim for a comprehensive consultation visit has been made with the preceding 12 months, then a repeat claim for this code shall be denied if made by the same physician, physician group, shared health care facility or physicians using a common record except in those instances where the consultation required the utilization of one hour or more of the physician's personal time. Otherwise, applicable codes would be Limited Consultation codes if their criteria are met.

(e) For reimbursement purposes, HCPCS 99241, 99242, 99243, 99251, 99252, 99253, 99271, 99272 and 99273 are considered "limited" because the consultation requires less than the requirements designated as "comprehensive" as noted in (c) above (Comprehensive consultation).

(f) When multiple special ophthalmological services or ophthalmoscopic services are billed on the same day for the same patient in an office setting, reimbursement shall be limited to the highest valued procedure.


15 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.14 (2014)
§ 10:62-1.14 Home services

(a) The House Call HCPCS 99343 and 99353 shall not apply to residential health care facility or nursing facility settings. These HCPCS refer to a physician visit limited to the provision of medical care to an individual who would be too ill to go to a physician's office and/or is "home bound" due to his or her physical condition. When billing for a second or subsequent patient treated during the same visit, the visit shall be billed as a home visit.

(b) For purposes of Medicaid or NJ FamilyCare fee-for-service reimbursement, HCPCS 99341, 99342, 99351 and 99352 apply when the provider visits a Medicaid or NJ FamilyCare fee-for-service beneficiary in the home setting and the visit does not meet the criteria specified under Home Visit listed in (a) above.

(c) In addition to the recordkeeping requirements indicated in N.J.A.C. 10:62-1.18, the record and documentation of a home visit shall become part of the office progress notes and shall include, as appropriate, the following information:

1. The purpose of the visit;

2. The pertinent history obtained;

3. Pertinent physical findings, including pertinent negative physical findings based on (c)1 and 2 above;

4. The procedures, if any performed, with results;

5. Lab, X-ray ECG, etc., ordered with results; and

6. A diagnosis(es) plus treatment plan status relative to present or pre-existing illness(es) plus pertinent recommendations and actions.


16 of 41 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 62. VISION CARE SERVICES MANUAL

SUBCHAPTER 1. EYE CARE: PROFESSIONAL SERVICES
N.J.A.C. 10:62-1.15 (2014)




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