NJ PIP $105 Daily Maximum: The 48 Codes on Exhibit 6
Exhibit 6 lists the 48 physical medicine and rehabilitation codes, 47 CPT and one HCPCS (G0283), that share a single $105 daily maximum. It carries no fee column, because $105 is not a fee. It is a ceiling on what one day of these services together can be reimbursed, across every provider the patient saw that day.
Exhibit 6 in full, all 48 rows
How to read this table
- Code
- A CPT or HCPCS code subject to the daily maximum. These are the physical medicine and rehabilitation codes the Department describes as commonly provided together.
- No fee column
- Exhibit 6 publishes none. The cap is measured against the provider's own usual and customary fees, not against a schedule amount, which is why no total can be computed from this file.
HCPCS codes
1 rows| Code | Description |
|---|---|
| G0283 | ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS |
Surgery, CPT 10000 to 69999
12 rows| Code |
|---|
| 29200 |
| 29240 |
| 29260 |
| 29280 |
| 29520 |
| 29530 |
| 29540 |
| 29550 |
| 29580 |
| 29581 |
| 29590 |
| 29799 |
Medicine, CPT 90000 to 99999
35 rows| Code |
|---|
| 97012 |
| 97016 |
| 97018 |
| 97022 |
| 97024 |
| 97026 |
| 97028 |
| 97032 |
| 97033 |
| 97034 |
| 97035 |
| 97036 |
| 97039 |
| 97110 |
| 97112 |
| 97113 |
| 97124 |
| 97139 |
| 97140 |
| 97150 |
| 97530 |
| 97535 |
| 97810 |
| 97811 |
| 97813 |
| 97814 |
| 98925 |
| 98926 |
| 98927 |
| 98928 |
| 98929 |
| 98940 |
| 98941 |
| 98942 |
| 98943 |
Source
- The schedule: N.J.A.C. 11:3-29 Appendix, Exhibit 6, published by the New Jersey Department of Banking and Insurance and effective for treatment rendered on or after January 4, 2013. It has not been amended since.
- Official files: the Department’s auto medical fee schedule page, the rule text and the Department’s own FAQ.
- This page: parsed from the Department’s Excel file, with every row count and every figure cross-checked against the Department’s PDF of the same exhibit. Free to download as one CSV of all seven exhibits, 7,553 rows, no sign-up.
What the rule says about this schedule
Is the $105 a per-provider cap or a per-day cap?
Per day, across every provider. FAQ Answer 10 puts it plainly: the limit of the insurer's liability for the Exhibit 6 codes is $105.00 per day, and it applies regardless of the number of providers the injured person visits. Two practices treating the same patient on the same day share one $105, they do not get one each.
This is the single most misread line in the New Jersey PIP fee schedule, and it cuts both ways in a real file. A carrier that paid $105 to each of three providers on one date has overpaid. A carrier that used the cap to zero out a fourth provider without first checking the day's total may have underpaid.
How is the $105 cap actually calculated?
FAQ Answer 11 gives the arithmetic. For the codes subject to the daily maximum, the insurer's limit of liability is the lesser of two numbers: the sum of the provider's usual, reasonable and customary fees for the services provided, without applying the multiple procedure reduction formula but with the NCCI edits applied, or the $105.00 daily maximum.
Read the first branch carefully. The comparison is against the provider's own usual and customary fees, not against fee schedule amounts, which is exactly why Exhibit 6 carries no fee column. No lookup tool built from this file can produce the capped day total, and any that claims to is inventing the first number. What a tool can honestly do is say which of the day's codes are on this list, which is what ours does.
When must an insurer pay more than $105 in a day?
When the injury needed extraordinary treatment and the provider can show it. 11:3-29.4(m) continues past the cap: where the provider demonstrates that the severity or extent of the injury is such that extraordinary time and effort is needed for effective treatment, the insurer shall reimburse in excess of the daily maximum. Shall, not may.
Those bills are submitted with modifier 22, the CPT modifier for unusual procedural services, and must be accompanied by documentation of why the extraordinary effort was needed unless it already went to the insurer in a decision point review or precertification request. The rule names severe brain injury and non-soft-tissue injuries to more than one part of the body as examples, and excludes diagnoses that have a care path under N.J.A.C. 11:3-4.
How many units of each code can be billed in a day?
One, for anything without a time increment in its description. 11:3-29.4(m)1 limits supervised modalities and therapeutic procedures that do not list a specific time increment to one unit per day. Codes that do name an increment, such as the 15-minute acupuncture and therapy codes on this list, are billed by that increment instead.
The same subsection fixes three codes by name. CPT 97012 is the code for powered traction therapy, CPT 97026 for cold or low-powered laser therapy, and HCPCS G0283 for unattended electrical stimulation. FAQ Answer 17 adds that where the Department has established the correct code by rule, an insurer need only evaluate medical necessity, whatever code a precertification request happened to carry.
Does the multiple procedure reduction apply to these codes?
No. FAQ Answer 11 says the reduction formula in 11:3-29.4(f) does not apply to services subject to the daily maximum, and the arithmetic it gives instead uses the provider's fees without applying that formula. The NCCI edits still apply, and 29.4(m) requires the insurer to use them in deciding whether the daily maximum was reached.
That is consistent with FAQ Answer 12, which confines the reduction formula to multiple and bilateral surgeries in the physicians' fee column, CPT 10000 through 69999. None of the 48 codes here is in that range.
What do the notes at the foot of Exhibit 6 say?
Three notes are printed on the exhibit itself, and they define what a region means for the manipulation codes. For chiropractic manipulative treatment, the five spinal regions are cervical (including the atlanto-occipital joint), thoracic (including the costovertebral and costotransverse joints), lumbar, sacral and pelvic (sacro-iliac joint).
For osteopathic manipulative treatment the body regions are head, cervical, thoracic, lumbar, sacral, pelvic, lower extremities, upper extremities, rib cage, and abdomen and viscera. The third note defines strapping as a replacement procedure used during or after follow-up care, or as an initial service performed without a restorative treatment, to stabilise or protect a fracture, injury or dislocation or to give the patient comfort. Separately, 11:3-29.4(g)4 bars kinesio taping from being billed under the strapping codes at all.