NEW JERSEY PIP FEE SCHEDULE
Introduction: New Jersey has implemented a PIP Fee Schedule which establishes a ceiling on the amount providers may charge in the State of New Jersey for treating patients injured in automobile accidents. [insert link to N.J.S.A. 39:6A-4.6 & N.J.A.C. 11:3-29.1]. The fee schedule was calculated based upon a regional basis and is broken into three Regions, based upon the first three digits of the provider’s zip code, as follows: FeeSchedule (note There has been a stay of old schedule for now)
Region I: zip codes starting with 080, 081, 082, 083, and 084.
Region II: zip codes starting with 077, 078, 079, 085, 086, 087, 088, and 089.
Region III: zip codes starting with 070, 071, 072, 073, 074, 075, and 076.
1. Effective October 27, 2004, the Attending Provider Treatment Plan form, attached as Appendix A to this Order, shall be used by all providers to submit Decision Point Review and Precertification Requests. No other forms for this purpose are permitted. Insurers and vendors are encouraged to program the form on their websites, so that it can be downloaded, completed and printed by the provider.
Holly C. Bakke Commissioner
Thus, to find out the maximum amount you may recover from a PIP carrier for procedures performed upon PIP patients:
1) Locate the zip code of your office and establish which Region you practice in;
3) Apply the fee schedule maximum amount under the column for your region.
Please note that there are different fee schedules for different years in which services were performed. Notably, the fee schedule underwent major amendments on July 16, 2001, and April 7, 2003. Thus, ensure you are looking at the appropriate fee schedule for the dates of service performed.
90 Dollar Per Day Cap
To further complicate things, a $90/per day cap applies to certain procedures that the Department of Banking and Insurance has deemed are "over-utilized" by providers in the state. Thus, regardless if the fee schedule amount of all procedures performed on a single day exceeds $90, the maximum amount any provider or number of providers may receive for treatment of a single patient in a single day for these capped modalities is $90.
For services provided prior to 4/7/03, the $90/per day cap applies to all CPT Codes between CPT 97001 and 98943.
For services provided after 4/7/03, the CPT codes in the following attachment are subject to the $90 cap. http://www.state.nj.us/dobi/acrobat/11329x6.pdf
The $90/per day cap may be waived by the PIP carrier, at their sole discretion, for extremely severe injuries such as severe brain injuries and non-soft tissue injuries to multiple body parts. If you feel a procedure should be exempt from the $90/per day cap, apply a -22 modifier to your billing and explain in your treatment notes why it should be exempt from the cap.
Multiple Modality Reduction
Another way that your fee is reduced for fee scheduled services is what is called the "Multiple Modality Reduction" or "MMR." This provides that when multiple or bilateral procedures are performed on the same patient during the same visit, it is virtually never appropriate for you to receive 100% of the fee scheduled amount for each modality. Rather, you are paid 100% of the fee schedule amount for the primary procedure; 50% for the second procedure; and 25% for any additional procedures. Thus, ensure that the first procedure you bill on the HCFA-1500 form is the main procedure you are performing with presumably the highest fee schedule rate. The next procedure billed should be the second most important procedure with presumably the next highest fee schedule rate, and so on.
The MMR does not apply to services that fall under the $90/per day. Rather, the amount you are reimbursed is the lesser of: 1) the sum of the provider’s usual reasonable and customary fees for the services provided without applying the reduction formula; or 2) the $90.00 daily maximum.
In addition, the MMR does not apply to diagnostic testing services such as x-rays or MRI scans.
Non-Fee Schedule CPT Codes:
If the procedure you performed on a PIP patient does not appear in the fee schedule, you are entitled to recover your Usual and Customary rate for this service. You may establish this by providing the PIP carrier with copies of Explanation of Benefit forms ("EOBs") from various insurance companies on other patients reimbursing you for the rates you are seeking on that claim. Please ensure that you blacken-out any personal health information on the EOBs before sending them so that you are HIPAA compliant.
Follow-Up Evaluation and Management Services
Follow-up evaluation and management services for the re-examination of an established patient may not be performed more than twice in a 30 day period unless any of the following exemptions applies:
If you feel any of the exemptions apply, append a -25 modifier to your evaluation and management CPT code and explain in your treatment notes the basis for the exemption.
Durable Medical Equipment Cap
With regard to durable medical equipment, the PIP carrier’s total limit of liability for a single piece of DME is 15 times the monthly rental fee listed in the fee schedule.
Prohibition of Balance Billing
The fee schedule specifically prohibits "balance billing," or billing the patient for the difference between the amount you charged and the amount received pursuant to the fee schedule ceiling. This also applies to liens on personal injury claims. Thus, your lien equals the fee scheduled amount (not gross amount) of your unpaid medical bills plus any co-pay and deductible not received from the patient directly.