MedicaidBilling CodesHigh impact
Newsletter Vol. 31, No.07
New Jersey Medicaid·NJ · Psychiatry, General Practice, Family Medicine·Pharmacy
Effective date
Apr 1, 2021
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid/NJ FamilyCare implemented significant restrictions on presumptive drug screening and definitive drug testing billing effective April 1, 2021. Multiple procedure codes were terminated, new HF (substance abuse program) modifiers were created with provider-type restrictions, and strict frequency/volume limits were imposed (max 1 encounter per date/10 per 30 days for presumptive; max 7 drug classes/2 encounters per 30 days for definitive). Claims will be denied if definitive testing follows negative presumptive results, if billed on same date as presumptive test, or if lacking prior presumptive test within 7 days.
Action Required
By April 1, 2021: Billing team must immediately update system logic to implement all code terminations and restrictions. SPECIFIC ACTIONS: (1) Terminate billing of G0434, G0481, G0482, G0483, 80102, and 80104 in all variants—claims using these codes will be denied; (2) Implement new HF-modifier codes (G0480 HF, 80305 HF, 80306 HF, 80307 HF) restricted to SUD Outpatient Treatment Providers only—verify provider type before billing; (3) Configure system to enforce maximum 1 presumptive drug test per date of service and maximum 10 per rolling 30 days per patient; (4) Configure system to enforce maximum 7 drug classes per date of service and maximum 2 definitive drug tests per rolling 30 days per patient; (5) Add hard-stop logic to deny definitive drug test claims (G0480/G0480 HF) billed on same date as presumptive test (80305/80306/80307 variants); (6) Add hard-stop logic to deny definitive drug test claims when NO paid presumptive test claim exists within 7 days prior; (7) Add hard-stop logic to deny ANY definitive drug test claims following documented negative presumptive results; (8) Deny claims bundling CPT 84311, 83986, 82570, 83789, 84315 with presumptive/definitive test codes on same date; (9) Update encounter forms and provider education materials to clarify standing vs. blanket order policies; (10) Implement post-payment audit monitoring for bundled codes and negative-result billing. Compliance team must audit historical claims back to April 1, 2021 for recoupment. Failure to implement will result in systematic claim denials and potential provider recoupment for non-compliant claims.