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PA Bulletin, Doc. No. 21-1541

NOTICES

DEPARTMENT OF
HUMAN SERVICES

Medical Assistance Program Fee Schedule Revisions; 2021 Healthcare Common Procedure Coding System Updates and Fee Adjustments; Prior Authorization Requirements

[51 Pa.B. 5914]
[Saturday, September 11, 2021]

 The Department of Human Services (Department) announces changes to the Medical Assistance (MA) Program Fee Schedule. These changes are effective for dates of service on and after August 23, 2021.

 The Department is adding and end-dating procedure codes as a result of implementing the 2021 updates published by the Centers for Medicare & Medicaid Services to the Healthcare Common Procedure Coding System (HCPCS). The Department is also adding other procedure codes and making changes to procedure codes currently on the MA Program Fee Schedule, to include fee adjustments. As follows, some of the procedure codes being added to the MA Program Fee Schedule will require prior authorization.

Procedure Codes Being Added or End-dated

 The Department is adding the following procedure codes, and procedure code and modifier combinations to the MA Program Fee Schedule as a result of the 2021 HCPCS updates. These procedure codes may include the modifiers SG (ASC/SPU facility support component), 80 (assistant surgeon), 26 (professional component) or TC (technical component).

Procedure Codes and Modifiers
3046830468 (SG)3240832408 (SG)33741
33741 (80)3374533745 (80)3374633746 (80)
7127171271 (26)71271 (TC)8018981168
8127992650926519265292653
9461994619 (26)94619 (TC)D1321D3471
D3471 (SG)D3472D3472 (SG)D3473D3473 (SG)
D3501D3501 (SG)D3502D3502 (SG)D3503
D3503 (SG)D7961D7961 (SG)D7962D7962 (SG)
G2213G2214G2215G2216

 The Department is end-dating the following procedure codes from the MA Program Fee Schedule as a result of the 2021 HCPCS updates:

Procedure Codes
19324 19366324054922057112
5829361870621636318063182
6960576970781359258592586
9299292993942509440094750
947709507199201D7960G0297

 The Department is adding the following procedure codes, and procedure code and modifier combinations to the MA Program Fee Schedule based upon clinical review. These procedure codes may include modifiers 26, TC and FP (Family Planning).

Procedure Codes and Modifiers
8751087510 (FP)904719047293351
93351 (26)93351 (TC) A9274

Prior Authorization Requirements

 For the following procedure codes, and procedure code and modifier combinations being added to the MA Program Fee Schedule, which are advanced radiology services, the Department will require prior authorization, under section 443.6(b)(7) of the Human Services Code (code) (62 P.S. § 443.6(b)(7)). The process for obtaining prior authorization is described in MA Bulletin 01-14-42, titled ''Advanced Radiologic Imaging Services,'' which may be viewed online at https://www.dhs.pa.gov/providers/FAQs/Documents/MA%20Bulletin%2001-14-42.pdf.

Procedure Codes and Modifiers
7127171271 (26)71271 (TC)

 The following procedure codes being added to the MA Program Fee Schedule require prior authorization, as authorized under section 443.6(b)(7) of the code:

Procedure Codes and Modifiers
8116881279

 The following dental procedure codes, and procedure codes and modifier combinations being added to the MA Program Fee Schedule require prior authorization, as authorized under section 443.6(b)(5) of the code:

Procedure Codes and Modifiers
D3471D3471 (SG)D3472 D3472 (SG)D3473
D3473 (SG)D3501D3501 (SG)D3502D3502 (SG)
D3503D3503 (SG)

Procedure Codes for Take-Home Supplies of Naloxone

 The Department is adding G2215 and G2216 as add-on procedures to the MA Program Fee Schedule to track the dispensing of take-home supplies of Naloxone. In order to identify when take-home supplies of Naloxone are dispensed, providers should use G2215 or G2216 in addition to one of the following procedure codes that are currently open on the MA Program Fee Schedule:

Procedure Codes
9920299203992049920599211
9921299213992149921599281
99282992839928499285T1015

Updates to Procedure Codes Currently on the MA Program Fee Schedule

Physicians' Services

 The GT (telemedicine) modifier is being removed for the following procedure codes and POS 02 (telemedicine) is being added for providers to identify when these services are provided by means of telemedicine.

Procedure Codes
9922199222992239923199232
9923399241

 The Department is adjusting the MA Program fee for the evaluation and management procedure codes identified as follows, effective August 23, 2021.


Procedure CodesCode DescriptionCurrent FeeNew Fee
99221Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the problems requiring admission are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit.$29.50 $79
99222Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the problems requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.$29.50 $106.37
99223Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the problems requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.$42 $156.63
99231Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit.$17 $30.06
99232Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit.$17 $56.22
99233Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.$17 $80.79

Ambulatory Surgical Center (ASC)/Short Procedure Unit (SPU) Services

 The Department is opening Provider Type (PT)/Specialty (Spec) combinations 01/021 (SPU), 02/020 (ASC), or both for the procedure codes identified as follows in Place of Service (POS) 24 (ASC) with the SG modifier as clinical review determined these procedure codes can be performed safely in a SPU, ASC, or both, depending on the procedure, and will be paid the facility support component fee of $776:

Procedure CodeNew PT/SpecPOS
19307 (SG)01/02124
27486 (SG)01/02124
63055 (SG) 01/021
02/020
24

 The Department is adding POS 24 for PT/Spec 31 (Physician)/All for the following procedure code and modifier combinations as a result of clinical review and the Department's determination that this setting is appropriate for the performance of these services. These procedure codes include modifiers 80, RT (right), LT (left) or 50 (bilateral), or both.

Procedure Code
19307 (RT)19307 (LT)19307 (50)19307 (80) (RT)19307 (80) (LT)
19307 (80) (50)27486 (RT)27486 (LT)27486 (50)27486 (80) (RT)
27486 (80) (LT)27486 (80) (50)6305563055 (80)

Laboratory Services

 The Department is adding the FP modifier for the following laboratory procedure code, as determined by clinical review, in the PT/Spec/POS combinations as indicated as follows:

Procedure Code New ModifierPT/SpecPOS
87480FP01/183 (Hospital Based Medical Clinic)22 (Outpatient Hospital)
08/083 (Family Planning Clinic) 22, 49 (Independent Clinic)
28/280 (Independent Laboratory)81 (Independent Laboratory)

 The Department is opening the following laboratory procedure codes with the FP modifier for PT/Spec combination 08/083 in POS 22 and 49, as determined by clinical review, indicated as follows:

Procedure Code and Modifier
87660 (FP)87661 (FP)

 The following laboratory procedure code has unit and service limitation updates with and without the FP modifier as a result of clinical review and National Correct Coding Initiative edits indicated as follows:

Procedure CodeOld Unit LimitNew Unit LimitPresent LimitNew Limit
874801:21:1Twice per dayOnce per day

Healthy Beginnings Plus (HBP) Program

 The Department is opening the following PT/Spec/POS combinations for procedure code 99241 with U9 (pricing) and HD (pregnant/parenting women's program) modifiers, indicated as follows, to allow for the billing of services provided in the HBP Program that were previously billed with the end-dated procedure code 99201.

Procedure CodeNew PT/SpecPOS
99241 (U9) (HD)01/18302, 22
05/050 (Home Health Agency) 02, 12 (Home)
08/080 (FQHC) 02, 12, 50 (FQHC)
08/081(RHC) 02, 12, 72 (RHC)
08/082 (Independent Medical/ Surgical Clinic) 02, 49
08/08302, 22, 49
31/All02, 11 (Office), 12, 99 (Special Treatment Room)
33/335 (Certified Nurse Midwives)02, 11, 99
47/470 (Birth Center)02, 11, 25 (Birth Center)

Psychiatric Outpatient and Drug and Alcohol Clinic Services

 The Department is opening the following PT/Spec/POS combinations for procedure code 99241 with U7 (pricing) or UB (pricing) modifiers, indicated as follows, to allow for the billing of services that were previously billed with the end-dated procedure code 99201.

Procedure Code Code DescriptionNew PT/SpecPOS
99241 (U7)Office consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the presenting problems are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient or family. (Chemotherapy clinic visit for administration and evaluation of drugs other than methadone or drugs for opiate detox.)08/184 (Outpatient Drug and Alcohol)57 (Nonresidential Substance Abuse Treatment Facility)
99241 (UB)Office consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the presenting problems are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient or family, or both. (Psychiatric clinic medication visit for drug administration and evaluation.)08/110 (Psychiatric Outpatient Clinic)49
08/074 (Mobile Mental Health)15 (Mobile Unit)

Durable Medical Equipment and Medical Supplies

 The Department is changing the limitations for medical supply procedure code E0603 (NU) from ''once per lifetime'' to ''once per calendar year'' based on clinical review. This procedure code with the NU modifier still requires prior authorization for purchase, under section 443.6(b)(2) of the code. Additionally, the Department is updating the fee for the medical supply procedure code indicated as follows.

Procedure CodeDescriptionCurrent FeeNew Fee
E0603 (NU)Breast pump, electric (AC or DC, or both), any type$267.53$180

Fiscal Impact

 The estimated cost for Fiscal Year 2021-2022 is $3.944 million. The estimated annualized fiscal impact is $5.916 million.

Public Comment

 Interested persons are invited to submit written comments regarding this notice to the Department of Human Services, Office of Medical Assistance Programs, c/o Regulations Coordinator, Attention: Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received will be reviewed and considered for any subsequent revisions to the MA Program Fee Schedule.

 Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania Hamilton Relay Service (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).

MEG SNEAD, 
Acting Secretary

Fiscal Note: 14-NOT-1462. (1) General Fund; (2) Implementing Year 2021-22 is $1,866,000; (3) 1st Succeeding Year 2022-23 through 5th Succeeding Year 2026-27 are $2,810,000; (4) 2020-21 Program—$808,350,000; 2019-20 Program—$344,107,000; 2018-19 Program—$342,544,000; (7) MA—Fee-for-Service; (8) recommends adoption. Funds have been included in the budget to cover this increase.

[Pa.B. Doc. No. 21-1541. Filed for public inspection September 10, 2021, 9:00 a.m.]



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