Effective Date: October 25, 2021

Purpose:

To provide guidelines for the reimbursement of revenue codes on outpatient and ancillary facility claims. 

Scope:

Products included:

• NJ Family Care/Medicaid

Policy:

Horizon NJ Health will require certain revenue codes to be billed with the corresponding CPT/HCPCS code when billed on an OP Facility claims (UB-04).The below revenue codes will only be considered for reimbursement on outpatient claims if billed with appropriate CPT/HCPCS code(s).

Revenue codes requiring CPT/HCPCS code

Procedure:

Horizon NJ Health will not consider for reimbursement when revenue codes are not billed with the corresponding CPT/HCPCS code on OP Facility claims (UB-04) as indicated in the policy.

Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

References:

Centers for Medicare & Medicaid Services (CMS), American Medical Association (AMA) Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS)