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Reimbursement Policies & Guidelines

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New Reimbursement Policy for Services Appended with Modifier 52

In order to align with Centers for Medicare & Medicaid Services standards, we have implemented a new reimbursement policy for services appended with Modifier 52 (Reduced Services). Effective January 1, 2015, Horizon NJ Health will reimburse services billed in conjunction with Modifier 52 at 50 percent of the applicable fee schedule amount.

Please be aware that Modifier 52 does not provide for reimbursement of an ineligible service and no additional reimbursement will be issued if the reimbursement is via capitation or captured in a global rate.

Note that the following CPT/HCPCS codes are excluded from this new Modifier 52 policy:

Code Modifier Description
T1024 52 Day Care Services, Medically Fragile, Per Diem
T2025 SE/52 Personal Care Services, Individual & Group
S9122 SE/52 MLTSS Personal Preference Program (PPP)
S5165 52 (GO Eval) Residential Modifications
S5120 52 Vehicle Modifications
Z7333 52 ADULT MH REHAB LEV AT SUP APT/DIEM
Z7334 52 ADULT MH REHAB LEV A SUP APART/DIEM
Z7335 52 ADULT MH REHAB LEV B SUP APT/15 MIN
Z7336 52 ADULT MH REHAB LEV C SUP APT/15 MIN
H0019 52/U1 ADULT MH REHAB LEV AT SUP APT/DIEM
H0019 52/U2 ADULT MH REHAB LEV A SUP APART/DIEM
H0019 52/U3 ADULT MH REHAB LEV B SUP APT/15 MIN
H0019 52/U4 ADULT MH REHAB LEV C SUP APT/15 MIN