Notification



Notification Issue Date:



Policy Attachment



Attachment to Policy # 00.10.01ab


Attachment:B

Policy #:00.10.01ab

Description:New Jersey Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers

Title:Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.


NEW JERSEY (NJ)
SERVICES PAID ABOVE CAPITATION FOR HEALTH MAINTENANCE ORGANIZATION (HMO) AND HEALTH MAINTENANCE ORGANIZATION POINT-OF-SERVICE (HMO-POS) PRIMARY CARE PHYSICIANS (PCPs)

NOTES:
  • The Effective Date indicates either the effective date of the code and/or the date the code became eligible for payment above capitation.
  • The Delete Date indicates either the date the code becomes invalid and/or the date the code is no longer eligible for payment above capitation.
  • NJ PCPs are eligible to receive payment above capitation for codes listed in the injectable drug and vaccine fee schedules. Injectable drug and vaccine codes are not included in the code list below.
  • NJ PCPs are eligible to receive payment above capitation for select Durable Medical Equipment and Supplies, such as cast/splints, crutches, canes. Durable Medical Equipment and Supplies are not included in the code list below.
SERVICES ELIGIBLE FOR PAYMENT ABOVE CAPITATION FOR NEW JERSEY PCPs
Code
Effective
Date
Delete
Date
0226T
07/01/10


12/31/2014
0227T
07/01/10
12/31/2014
0403T
01/01/16
10040
10/01/05
10060
11/01/93
10061
11/01/93
10080
03/01/03
10120
11/01/93
10140
10/01/05
10160
10/01/05
11040
10/01/05
01/01/11
11041
10/01/05
01/01/11
11045
01/01/11
11046
01/01/11
11047
01/01/11
11055
10/01/05
11056
10/01/05
11057
10/01/05
11100
10/01/05
01/01/2019
11101
10/01/05
01/01/2019
11102
01/01/2019
11103
01/01/2019
11104
01/01/2019
11105
01/01/2019
11106
01/01/2019
11107
01/01/2019
11200
11/01/93
11201
11/01/93
11300
11/01/93
11301
11/01/93
11302
11/01/93
11303
11/01/93
11305
11/01/93
11306
11/01/93
11307
11/01/93
11308
11/01/93
11310
11/01/93
11311
11/01/93
11312
11/01/93
11313
11/01/93
11400
11/01/93
11401
11/01/93
11402
11/01/93
11403
11/01/93
11404
11/01/93
11406
11/01/93
11420
11/01/93
11421
11/01/93
11422
11/01/93
11423
11/01/93
11424
11/01/93
11426
11/01/93
11440
11/01/93
11441
11/01/93
11442
11/01/93
11443
11/01/93
11444
11/01/93
11446
11/01/93
11600
10/01/05
11601
10/01/05
11602
10/01/05
11603
10/01/05
11604
10/01/05
11606
01/01/10
11620
10/01/05
11621
10/01/05
11622
10/01/05
11623
10/01/05
11624
01/01/10
11626
01/01/10
11640
01/01/10
11641
01/01/10
11730
10/01/05
11732
10/01/05
11740
10/01/05
11900
10/01/05
11901
10/01/05
11975
08/04/00
12/31/11
11976
08/04/00
11977
08/04/00
12/31/11
12001
11/01/93
12002
11/01/93
12004
03/01/03
12005
03/01/03
12006
03/01/03
12007
03/01/03
12011
03/01/03
12013
03/01/03
12014
03/01/03
12015
03/01/03
12016
03/01/03
12017
03/01/03
12018
03/01/03
12020
03/01/03
12021
03/01/03
12031
10/01/05
12032
10/01/05
12034
10/01/05
12035
10/01/05
12041
10/01/05
12042
10/01/05
12044
10/01/05
12045
10/01/05
12051
10/01/05
12052
10/01/05
12053
10/01/05
12054
10/01/05
16000
11/01/93
16020
11/01/93
17000
03/01/03
17003
03/01/03
17004
03/01/03
17110
10/01/05
17111
10/01/05
17260
10/01/05
17261
10/01/05
17262
10/01/05
17263
10/01/05
17280
10/01/05
17281
10/01/05
17282
10/01/05
19000
10/01/05
19001
10/01/05
20550
03/01/03
20551
10/01/05
20552
10/01/05
20553
10/01/05
20600
11/01/93
20604
01/01/15
20605
11/01/93
20606
01/01/15
20610
11/01/93
20611
01/01/15
20612
10/01/05
21315
11/01/93
21337
11/01/93
21800
11/01/93
12/31/2014
21930
10/01/05
23500
11/01/93
23540
11/01/93
23570
11/01/93
24065
10/01/05
24200
11/01/93
24640
11/01/93
25600
10/01/05
26010
10/01/05
26720
11/01/93
26750
10/01/05
27086
11/01/93
27200
11/01/93
27327
10/01/05
28043
10/01/05
28190
11/01/93
28510
11/01/93
30300
02/10/97
30901
10/01/05
31500
02/10/97
32000
10/01/05
12/31/07
32421
01/01/08
01/01/13
36510
02/10/97
36620
02/10/97
36660
02/10/97
45307
11/01/93
10/01/05
45330
03/01/03
45331
03/01/03
10/01/05
45332
11/01/93
10/01/05
46320
10/01/05
46600
10/01/05
46608
11/01/93
46900
10/01/05
46910
10/01/05
46916
03/01/03
46922
10/01/05
46924
03/01/03
46930
01/01/09
51000
10/01/05
12/31/07
51100
01/01/08
51701
04/18/05
51702
04/18/05
51703
04/18/05
54000
11/16/99
54001
11/16/99
54050
10/01/05
54055
10/01/05
54056
03/01/03
54150
06/01/93
54160
06/01/93
56405
10/01/05
56420
10/01/05
56501
03/01/03
56515
03/01/03
56605
10/01/05
56606
10/01/05
57061
03/01/03
57065
03/01/03
57135
10/01/05
57452
03/01/03
57454
03/01/03
57460
10/01/05
57511
03/01/03
58100
03/01/03
58300
08/04/00
58301
08/04/00
62270
10/01/05
64405
10/01/05
64450
10/01/05
64455
01/01/09
65205
06/01/93
69200
11/01/93
86580
11/01/93
86585
11/01/93
10/01/05
86710
11/01/01
87070
01/01/01
87081
01/01/01
87501
08/19/2019
87502
08/19/2019
87503
08/19/2019
87275
08/19/2019
87276
08/19/2019
87400
08/19/2019
87804
11/01/01
87880
11/01/94
87899
11/01/01
90460
01/01/11
90461
01/01/11
90465
01/01/07
01/01/11
90466
01/01/07
01/01/11
90467
01/01/07
01/01/11
90468
01/01/07
01/01/11
90470
09/28/09
09/22/10
90471
01/01/07
90472
01/01/07
90473
01/01/07
90474
01/01/07

SERVICES ELIGIBLE FOR PAYMENT ABOVE CAPITATION FOR NEW JERSEY PCPs
Code
Effective
Date
Delete
Date
92227

10/01/17
92550
01/01/10
92551
01/01/92
92567
11/01/93
92570
01/01/10
92585
01/01/02
92586
01/01/02
92587
01/01/02
92588
01/01/02
93000
11/01/93
93015
10/01/05
93224
04/01/12
93230
11/01/93
01/01/11
94010
11/01/93
94060
10/01/05
94640
11/01/93
94664
07/01/98
10/01/05
94664
03/18/2016
95115
10/01/05
95117
10/01/05
95145
01/01/98
10/01/05
95145
03/18/16
95146
01/01/98
10/01/05
95146
03/18/16
95147
01/01/98
10/01/05
95147
03/18/16
95148
01/01/98
10/01/05
95148
03/18/16
95149
01/01/98
10/01/05
95149
03/18/16
95165
01/01/98
10/01/05
95165
03/18/16
95170
01/01/98
10/01/05
95170
03/18/16
96127
01/01/15
97802
07/01/07
97803
07/01/07
97804
07/01/07
97810
01/01/19
97811
01/01/19
97813
01/01/19
97814
01/01/19
98925
01/01/97
98926
01/01/97
98927
01/01/97
98928
01/01/97
98929
01/01/97
98960
08/01/08
98961
08/01/08
98962
08/01/08
99050
01/01/97
10/01/05
99052
11/01/94
10/01/05
99054
11/01/94
10/01/05
99078
08/01/08
99170
08/01/01
99173
01/01/12
99188
01/01/15
99217
01/01/12
99218
01/01/12
99219
01/01/12
99220
01/01/12
99221
01/01/12
99222
01/01/12
99223
01/01/12
99224
01/01/12
99225
01/01/12
99226
01/01/12
99231
01/01/12
99232
01/01/12
99233
01/01/12
99234
01/01/12
99235
01/01/12
99236
01/01/12
99238
01/01/12
99239
01/01/12
99291
11/01/94
99292
10/01/01
99295
11/01/93
12/31/08
99296
11/01/93
12/31/08
99297
11/01/93
12/31/03
99301
10/01/01
12/31/05
99302
10/01/01
12/31/05
99303
10/01/01
12/31/05
99304
01/01/06
99305
01/01/06
99306
01/01/06
99307
01/01/06
99308
01/01/06
99309
01/01/06
99310
1/01/06
99311
10/01/01
12/31/05
99312
10/01/01
12/31/05
99313
10/01/01
12/31/05
99315
01/01/06
99316
01/01/06
99318
01/01/06
99321
10/01/01
12/31/05
99322
10/01/01
12/31/05
99323
10/01/01
12/31/05
99324
01/01/06
99325
01/01/06
99326
01/01/06
99327
01/01/06
99328
01/01/06
99331
10/01/01
12/31/05
99332
10/01/01
12/31/05
99333
10/01/01
12/31/05
99334
01/01/06
99335
01/01/06
99336
01/01/06
99337
01/01/06
99341
10/01/94
99342
10/01/94
99343
10/01/94
99344
10/01/01
99345
10/01/01
99347
10/01/94
99348
10/01/94
99349
10/01/94
99350
10/01/01
99354
11/01/94
99355
11/01/94

SERVICES ELIGIBLE FOR PAYMENT ABOVE CAPITATION FOR NEW JERSEY PCPs
Code
Diagnosis Code
Effective
Date
Delete
Date
99356
11/01/94
99359
11/01/93
99360
10/01/94
07/01/04
99374
10/01/05
99384
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99385
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99386
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99387
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99394
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99395
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99396
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99397
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99431
01/01/92
12/31/08
99432
11/01/94
12/31/08
99433
11/01/93
12/31/08
99436
01/01/98
12/31/08
99440
11/01/93
12/31/08
99460
01/01/09
99461
01/01/09
99462
01/01/09
99463
01/01/09
99464
01/01/09
99465
01/01/09
99468
01/01/09
99469
01/01/09

SERVICES ELIGIBLE FOR PAYMENT ABOVE CAPITATION FOR NEW JERSEY PCPs
Code
Effective
Date
Delete
Date
A4310
04/18/05
A4311
04/18/05
A4312
04/18/05
A4313
04/18/05
A4314
04/18/05
A4315
04/18/05
A4316
04/18/05
A4326
08/01/08
A4327
08/01/08
A4328
08/01/08
A4333
04/18/05
A4334
04/18/05
A4336
01/01/10
A4337
01/01/2016
A4338
04/18/05
A4340
04/18/05
A4344
07/01/04
A4346
07/01/04
A4348
07/01/04
01/01/07
A4349
04/18/05
A4351
04/18/05
A4352
04/18/05
A4353
04/18/05
A4354
04/18/05
A4357
04/18/05
A4358
04/18/05
A4359
04/18/05
01/01/07
A4360
01/01/10
A5056
01/01/12
A5057
01/01/12
A5102
04/18/05
A5105
04/18/05
A5112
04/18/05
A5113
04/18/05
A5114
04/18/05
A5200
04/18/05
G0008
01/01/07
G0009
01/01/07
G0010
01/01/07
G0108
08/01/08
G0109
08/01/08
G0270
07/01/07
G0271
07/01/07
G9141
09/15/09
09/22/10
Q4074
01/01/10
S0610
07/01/03
S0612
07/01/03
S8930
01/01/19
S9140
08/01/08
S9141
08/01/08
S9449
07/01/07
S9452
07/01/07
S9455
08/01/08
S9460
08/01/08
S9465
08/01/08
S9470
07/01/07
Version Effective Date: 08/19/2019
Version Issued Date: 08/19/2019
Version Reissued Date: N/A



2017 AmeriHealth.