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New Jersey MedicaidMedicaid · Billing Codes · Pharmacy · NJ · Psychiatry, General Practice, Family MedicineHigh impact

Newsletter Vol. 31, No.07

Act
by Apr 1, 2021
Effective date
Apr 1, 2021
Identified
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.

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What to do

by Apr 1, 2021 · 12 steps
01Billing team must immediately update system logic to implement all code terminations and restrictions.
02Terminate billing of G0434, G0481, G0482, G0483, 80102, and 80104 in all variants—claims using these codes will be denied.
03Implement new HF-modifier codes (G0480 HF, 80305 HF, 80306 HF, 80307 HF) restricted to SUD Outpatient Treatment Providers only—verify provider type before billing.
04Configure system to enforce maximum 1 presumptive drug test per date of service and maximum 10 per rolling 30 days per patient.
05Configure system to enforce maximum 7 drug classes per date of service and maximum 2 definitive drug tests per rolling 30 days per patient.
06Add hard-stop logic to deny definitive drug test claims (G0480/G0480 HF) billed on same date as presumptive test (80305/80306/80307 variants).
07Add hard-stop logic to deny definitive drug test claims when NO paid presumptive test claim exists within 7 days prior.
08Add hard-stop logic to deny ANY definitive drug test claims following documented negative presumptive results.
09Deny claims bundling CPT 84311, 83986, 82570, 83789, 84315 with presumptive/definitive test codes on same date.
10Update encounter forms and provider education materials to clarify standing vs. blanket order policies.
11Implement post-payment audit monitoring for bundled codes and negative-result billing.
12Compliance team must audit historical claims back to April 1, 2021 for recoupment.
If missed: Failure to implement will result in systematic claim denials and potential provider recoupment for non-compliant claims.

Codes mentioned

G0434G0480G0481G0482G048380102801048030580306803078431183986825708378984315

Original notice

Newsletter Vol. 31, No.07
njmmis.com · Always check the source before changing claims.
View original ↗

Related changes

See all New Jersey Medicaid changes →
Newsletter Vol. 36, No.08HighEffective Apr 1, 2021 · PharmacyNewsletter Vol. 31, No.11HighEffective Apr 1, 2021 · PharmacyNewsletter Vol. 21, No. 20HighEffective Oct 1, 2011 · PharmacyNewsletter Vol. 22, No.01HighEffective Oct 1, 2011 · PharmacyBrowse every New Jersey Medicaid change in the policy list

Related policy hubs

New Jersey Medicaid policiesNJ policy changesPsychiatryGeneral PracticeFamily MedicineCode G0434Code G0480Code G0481Code G0482Code G0483Code 80102Code 80104Code 80305Code 80306Code 80307Code 84311Code 83986Code 82570Code 83789Code 84315

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