NOTICES
Medical Assistance Program Fee Schedule Revisions; 2003 HCPCS Updates; Prior Authorization Requirements
[34 Pa.B. 4790] By this notice, the Department of Public Welfare (Department) announces several changes to the Medical Assistance (MA) Program Fee Schedule and accompanying prior authorization requirements.
Fee Schedule Revisions
The Department is adding and end dating procedure codes as a result of implementing the 2003 updates made by the Centers for Medicare and Medicaid Services to the Healthcare Common Procedure Coding System (HCPCS). The 2003 HCPCS codes are effective for dates of service on and after January 1, 2004.
In addition to the HCPCS updates, the Department is adding procedure code G0234 with effective dates of service on and after July 1, 2004. Procedure code G0234 is being added because the Department has received a significant number of requests for that service through the program exception process authorized by 55 Pa. Code § 1150.63 (relating to waivers).
Effective with dates of service on and after July 1, 2004, the Department is revising the fees for several existing procedure codes. Specifically, the Department is adjusting the fees for the following existing procedure codes for neonatal and pediatric services so that payment rates for these procedure codes remain consistent with payment rates for the procedure codes added as a result of the HCPCS updates:
99295 Old Fee: $450 New Fee: $703.91 99296 Old Fee: $230 New Fee: $309.43 99298 Old Fee: $80 New Fee: $108.56 In addition, the Department is reducing the fee for procedure code 58611 to reflect an appropriate payment rate to comply with the State Plan requirement that Pennsylvania Medicaid fees not exceed Medicare reimbursement fees:
58611 (surgeon) Old Fee: $876 New Fee: $74.91 58611 (asst. surgeon) Old Fee: $175.20 New Fee: $14.86 Fees for the added procedure codes will be published in a Medical Assistance Bulletin that will be issued to all providers within a few weeks.
Prior Authorization Requirements
The following new HCPCS procedure codes are for items of durable medical equipment that cost more than $100 and therefore are subject to prior authorization under 62 P. S. § 443.6(b)(2):
A7025 High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each A7030 Full face mask used with positive airway pressure device, each E0117 Crutch, underarm, articulating, spring assisted, each E0701 Helmet with face guard and soft interface material, prefabricated E1012 Integrated seating system, planar, for pediatric wheelchair E1013 Integrated seating system, contoured, for pediatric wheelchair E1014 Reclining back, addition to pediatric wheelchair E1016 Shock absorber for power wheelchair, each E1020 ''Residual limb support system for wheelchair'' E1161 Manual adult size wheelchair, includes tilt in space E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system E1236 Wheelchair, pediatric size, folding, adjustable, with seating system E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system E1238 Wheelchair, pediatric size, folding, adjustable, without seating system L0450 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panels, includes shoulder straps and closures, prefabricated, includes fitting and adjustment L0452 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panels, includes shoulder straps and closures, custom fabricated L0454 TLSO flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panels, includes shoulder straps and closures, prefabricated, includes fitting and adjustment L0456 TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, includes fitting and adjustment L0458 TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and tranverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment L0460 TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and tranverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment L0462 TLSO, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment L0464 TLSO, triplanar control, modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and tranverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment L0466 TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment L0468 TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment L0470 TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and tranverse planes, produces intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment L0472 TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment L0474 TLSO, triplanar control, rigid posterior frame with flexible soft apron anterior with multiple straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in the sagittal, coronal, and tranverse planes, produces intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment L0476 TLSO, sagittal-coronal control, flexion compression jacket, two rigid plastic shells with soft liner, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, usually laced together on one side, restricts gross trunk motion in sagittal and coronal planes, allows free flexion and compression of the LS region, includes straps and closures, prefabricated, includes fitting and adjustment L0478 TLSO, sagittal-coronal control, flexion compression jacket, two rigid plastic shells with soft liner, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, usually laced together on one side, restricts gross trunk motion in sagittal and coronal planes, allows free flexion and compression of LS region, includes straps and closures, custom fabricated L0480 TLSO, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated L0482 TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated L0484 TLSO, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated L0486 TLSO, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated L0488 TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment L0490 TLSO, sagittal-coronal control, one piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment L1652 Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type L1836 Knee orthosis, rigid, without joints, includes soft interface material, prefabricated, includes fitting and adjustment L3652 Shoulder orthosis, double shoulder, elastic, prefabricated, includes fitting and adjustment (for example, neoprene, lycra) L4386 Non-pneumatic walking splint, with or without joints, prefabricated, includes fitting and adjustment L5781 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system L5848 Addition to endoskeletal, knee-shin system, hydraulic stance extension, dampening feature, adjustable L6025 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device L6638 Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow L6646 Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system L6647 Upper extremity addition, shoulder lock mechanism, body powered actuator L6648 Upper extremity addition, shoulder lock mechanism, external powered actuator L7367 Lithium ion battery, replacement L7368 Lithium ion battery charger The following new HCPCS procedure codes are subject to prior authorization, as authorized in 62 P. S. § 443.6(b)(7):
G0234 Positive emission tomography, regional or whole body, for solitary pulmonary nodule following CT or for initial staging of pathologically diagnosed nonsmall cell lung cancer; gamma cameras only J7342 Dermal tissue, of human origin, with or without other bioengineered or processed elements, with metabolically active elements, per square centimeter
Changes to the MA Program Fee Schedule for Provider Types
01, 02, 03, 07, 08, 12, 15, 18, 25, 26, 29, 31, 33, 34, 47, 59
Procedure Codes Added to the Fee Schedule as a Result of the Updates and Additions which are Effective and Compensable for Dates of Service as of January 1, 2004
Procedure Code Modifiers Procedure Code Modifiers Procedure Code Modifiers A4266 A4267 A4268 A4281 A4282 A4283 A4284 A4285 A4286 A4405 A4406 A4407 A4408 A4409 A4410 A4413 A4414 A4415 A4422 A4450 A4452 A4525 A4526 A4527 A4528 A4531 A4532 A4534 A4609 A4610 A4633 A4930 A4931 A4932 A6011 A6410 A6411 A6421 A7025 A7026 A7030 A7031 A7032 A7033 A7034 A7035 A7036 A7037 A7038 A7039 A7044 B4100 E0117 NU E0454 RR E0461 RR E0483 RR E0484 NU E0618 RR E0636 RR E0701 NU E1012 NU, RR E1013 NU, RR E1014 NU, RR E1015 NU, RR E1016 NU, RR E1020 NU, RR E1025 NU, RR E1026 NU, RR E1027 NU, RR E1037 RR E1038 RR E1161 NU, RR E1232 NU, RR E1233 NU, RR E1234 NU, RR E1235 NU, RR E1236 NU, RR E1237 NU, RR E1238 NU, RR E1802 RR L0450 L0452 L0454 L0456 L0458 L0460 L0462 L0464 L0466 L0468 L0470 L0472 L0474 L0476 L0478 L0480 L0482 L0484 L0486 L0488 L0490 L1652 L1836 L1901 L3651 L3652 L3701 L3762 L3909 L3911 L4386 L5781 L5848 L6025 L6638 L6646 L6647 L6648 L7367 L7368 G0234 26, TC G0269 SG G0290 SG G0291 SG J7342 0031T SG 20612 SG 21046 SG 21047 SG 21048 SG 21049 SG 21742 80, SG 21743 80, SG 29827 SG 29873 SG 29899 SG 33215 SG 33224 SG 33225 SG 33226 SG 33508 80 34833 80 34834 80 34900 80 35572 80 36511 SG 36512 SG 36513 SG 36514 SG 36515 SG 36516 SG 37182 80 37183 80 37500 80, SG 38205 SG 38206 SG 38242 SG 43201 SG 43236 SG 44206 80 44207 80 44208 80 44210 80 44211 80 44212 80 44701 80 45335 SG 45340 SG 45381 SG 45386 SG 46706 SG 49419 SG 49904 80 50542 80, SG 50543 80, SG 50562 SG 51701 51702 51703 SG 51798 55866 80 56820 SG 56821 SG 57420 SG 57421 SG 57455 SG 57456 SG 57461 SG 58146 80, SG 58290 80, SG 58291 80 58292 80 58293 80 58294 80 58545 80, SG 58546 80, SG 58552 80, SG 58553 80, SG 58554 80, SG 61316 80 61322 80 61323 80 61517 80 61623 80, SG 62148 80, SG 62160 80, SG 62161 80, SG 62162 80, SG 62163 80, SG 62164 80, SG 62165 80, SG 64416 SG 64446 SG 64447 SG 64448 SG 75901 26, TC 75902 26, TC 75954 26 76071 26, TC 76801 26, TC 76802 26, TC 76811 26, TC 76812 26, TC 76817 26, TC 83880 84302 85004 85032 85049 85380 87255 87267 87271 88174 88175 89055 92601 92602 92603 92604 92610 92611 92612 92613 92614 92615 92616 92617 93580 93581 95990 96920 SG 96921 SG 96922 SG 99293 99294 99299 E0951
Procedure Codes deleted from the Fee Schedule as a Result of the Updates which will not be Compensable for Services Provided After August 31, 2004:
Procedure Codes A4370 G0015 L0310 L0390 L0950 47133 94665 A4374 K0021 L0315 L0391 L0986 58551 99297 A4386 K0034 L0317 L0400 L5660 85021 A4572 K0101 L0320 L0410 L5662 85022 A5123 K0183 L0321 L0420 L5663 85023 A6405 K0184 L0330 L0430 L5664 85024 A6406 K0185 L0331 L0440 21041 85031 E0608 K0186 L0340 L0900 33930 85590 G0004 K0187 L0350 L0910 33940 85595 G0005 K0188 L0360 L0920 36520 87198 G0006 K0189 L0370 L0930 36521 87199 G0007 L0300 L0380 L0940 38231 90709 Fiscal Impact
The fiscal note was prepared under provision of section 612 of The Administrative code of 1929 (71 P. S. § 232). The estimated cost for Fiscal Year 2003-2004 is $1.287 million ($0.582 million in State funds). The estimated cost for Fiscal Year 2004-2005 is $3.861 million ($1.773 million in State funds).
Public Comment
Interested persons are invited to submit written comments to this notice within 30 days of this publication to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received will be considered in subsequent revisions to the fee schedule. Persons with a disability may use the AT&T Relay Services, (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-NOT-393. (1) General Fund; (2) Implementing Year 2003-04 is $582,000; (3) 1st Succeeding Year 2004-05 is $1,773,000; 2nd Succeeding Year 2005-06 is $1,782,000; 3rd Succeeding Year 2006-07 is $1,782,000; 4th Succeeding Year 2007-08 is $1,782,000; 5th Succeeding Year 2008-09 is $1,782,000; (4) 2002-03 Program--$668,832,000; 2001-02 Program--$705,750,000; 2000-01 Program--$668,586,000; (7) Medical Assistance--Outpatient; (8) recommends adoption. The previous costs have been included in the Fist Supplemental General Appropriation Act of (2003) (Act 9A) and the General Appropriation Act of 2004 (Act 7A).
[Pa.B. Doc. No. 04-1613. Filed for public inspection August 27, 2004, 9:00 a.m.]
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