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Newsletter Vol. 25, No.14
Act
by Oct 1, 2015 (or immediately for current claims)
Effective date
Oct 1, 2015
Identified
Jun 20, 2026
Summary
New Jersey FamilyCare updates ICD-10-CM diagnosis codes required for prior authorization and reimbursement of outpatient hospital dental services provided in operating rooms to beneficiaries with developmental disabilities and/or chronic medical conditions. Hospitals must report specific revenue codes (OP 360 or OP 512) and qualifying ICD-10-CM diagnosis codes on claims with service dates on or after October 1, 2015. Prior authorization requires CDT code D9999, medical documentation, clinical justification, and treatment summary.
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What to do
by Oct 1, 2015 (or immediately for current claims) · 6 steps
01Billing team and dental providers must update systems to require prior authorization for all outpatient hospital dental services using CDT code D9999 on MC-10 forms.
02Providers must submit medical documentation on office letterhead including: beneficiary's medical condition and ICD-10-CM diagnosis code from the approved list, clinical justification explaining why office/clinic setting is not viable and why alternative sedation is not an option, and planned treatment details with 12-month dental history.
03Hospital billing must report only Revenue Code OP 360 or OP 512 for operating room charges and include one or more qualifying ICD-10-CM diagnosis codes from the attached list.
04Update billing software to enforce correct revenue codes and diagnosis codes based on service date (ICD-10 for October 1, 2015 forward; ICD-9 for dates prior to October 1, 2015).
05Train billing staff that claims missing correct revenue codes or invalid diagnosis codes will be denied with Error Code 1310.
06For claims prior to October 1, 2015, continue using ICD-9-CM codes from Medicaid Newsletter Volume 22, No. 18 and disregard the November 2012 version of this newsletter.
Codes mentioned
D9999E75E756F03F0391F06F068F07F079F09F48F489F53F60F609F70F71F72F73F78F79F84F849F88F89F90F909F91F919G10G25G259G31G319G40G409G71G719G72G729G73G737G80G809G93G939P04P049Q86Q90Q99R56R569S06S069X9F819I6783P154P158P159
Original notice
Newsletter Vol. 25, No.14
njmmis.com · Always check the source before changing claims.
Related changes
See all New Jersey Medicaid changes →Medicaid Alert MA-2025-03MediumEffective Oct 1, 2025 · EligibilityNewsletter Vol. 14, No. 16HighEffective Apr 1, 2004 · Provider NoticeNewsletter Vol. 22, No.18MediumEffective Nov 1, 2012 · EligibilityMedicaid Alert MA-2023-06MediumNo effective date · Provider NoticeBrowse every New Jersey Medicaid change in the policy list
Related policy hubs
New Jersey Medicaid policiesNJ policy changesDentistryOral & Maxillofacial SurgeryPediatricsPsychiatryNeurologyGeneral SurgeryCode D9999Code E75Code E756Code F03Code F0391Code F06Code F068Code F07Code F079Code F09Code F48Code F489Code F53Code F60Code F609Code F70Code F71Code F72Code F73Code F78Code F79Code F84Code F849Code F88Code F89Code F90Code F909Code F91Code F919Code G10Code G25Code G259Code G31Code G319Code G40Code G409Code G71Code G719Code G72Code G729Code G73Code G737Code G80Code G809Code G93Code G939Code P04Code P049Code Q86Code Q90Code Q99Code R56Code R569Code S06Code S069X9Code F819Code I6783Code P154Code P158Code P159