NOTICES
DEPARTMENT OF
PUBLIC WELFARE
Medical Assistance Program Fee Schedule Procedure Code Changes for Durable Medical Equipment, Medical Supplies, Vision Supplies and Hearing Supplies; Prior Authorization Requirements
[35 Pa.B. 6707] The Department of Public Welfare (Department) announces several changes to the Medical Assistance (MA) Program Fee Schedule for procedure codes for durable medical equipment, medical supplies, vision supplies and hearing supplies and the accompanying prior authorization requirements.
Fee Schedule Revisions
The Department is end-dating the following local procedure codes for durable medical equipment and medical supplies. Those local procedure codes will not be compensable for services provided after December 11, 2005.
Local Procedure Code Local Procedure Code Local Procedure Code Local Procedure Code W0202 Y9939 Z1351 Z4452 W1765 Y9953 Z1400 Z4454 W4405 Y9957 Z1401 Z4455 W4406 Y9958 Z1402 Z4456 W4407 Y9959 Z1403 Z4457 W4408 Y9964 Z1404 Z4458 W4409 Y9965 Z1406 Z4459 W4410 Y9966 Z1408 Z4491 W8697 Y9970 Z1826 Z4511 W9884 Z0043 Z2161 Z4553 Y0012 Z0053 Z2162 Z4561 Y0017 Z0241 Z2163 Z4562 Y0034 Z0242 Z3062 Z4600 Y2021 Z0243 Z3064 Z4611 Y5241 Z0244 Z3091 Z4612 Y5242 Z0246 Z3092 Z4613 Y5298 Z0247 Z3255 Z4615 Y8938 Z0248 Z3257 Z4616 Y9400 Z0249 Z3731 Z4617 Y9401 Z0250 Z4140 Z4618 Y9640 Z0281 Z4141 Z4619 Y9641 Z0334 Z4210 Z4620 Y9642 Z0460 Z4211 Z4621 Y9651 Z0461 Z4217 Z4622 Y9652 Z0521 Z4219 Z4623 Y9655 Z0522 Z4251 Z4624 Y9656 Z0523 Z4252 Z4625 Y9657 Z0524 Z4253 Z4626 Y9658 Z0527 Z4256 Z4637 Y9659 Z0530 Z4262 Z4650 Y9660 Z0531 Z4264 Z4651 Y9661 Z0532 Z4266 Z4652 Y9662 Z0533 Z4297 Z7501 Y9666 Z0534 Z4330 Z7511 Y9667 Z0536 Z4338 Z8907 Y9668 Z0555 Z4340 Z9002 Y9669 Z0600 Z4342 Z9003 Y9670 Z0625 Z4348 Z9005 Y9894 Z0935 Z4354 Z9006 Y9895 Z0936 Z4355 Z9007 Y9924 Z0950 Z4356 Z9008 Y9926 Z0977 Z4373 Z9010 Y9928 Z0980 Z4374 Z9800 Y9929 Z0981 Z4376 Z9801 Y9930 Z1091 Z4378 Z9805 Y9932 Z1092 Z4379 Z9806 Y9933 Z1093 Z4382 Z9809 Y9934 Z1094 Z4384 Z9810 Y9935 Z1095 Z4403 Z9811 Y9938 Z1096 Z4451 Z9814 Except as set forth as follows, these local codes are being cross walked to either existing National codes or new National procedure codes that are being added to the MA Program Fee Schedule.
Local procedure code Z9800 is being end-dated and not cross walked to a National procedure code. Pharmacy providers can bill for this item from the Drug Reference File.
Local procedure code Y9661 is being cross walked to National procedure code E0935. National procedure code E0935 can only be used for the rental of the passive motion exercise device. Therefore, effective with dates of service December 12, 2005, the Department will only allow for the rental, not the purchase, of this durable medical equipment item.
Local procedure code W0202 is being cross walked to National procedure code E0445. The local procedure code only allowed for the rental of the pulse oximeter. With advances in medical technology, the purchase price for a pulse oximeter has decreased over the years since the local procedure code was added to the MA Program Fee Schedule, making it more cost effective for the Department to pay for the purchase of a pulse oximeter rather than paying for continuous rental. For this reason, the Department is adding a purchase fee for E0445 to the MA Program Fee Schedule and reducing the fee for rental.
Effective with dates of service December 12, 2005, the Department is adding the following new National procedure codes and modifiers to the MA Program Fee Schedule.
National Procedure Code Pricing Modifier Informational Modifier MA Fee A4206 $ 0.29 A4207 $ 0.29 A4208 $ 0.29 A4209 $ 0.29 A4213 $ 0.29 A4213 U8 $ 0.88 A4215 $ 0.18 A4221 $ 18.12 A4222 $ 28.00 A4335 U8 $ 0.75 A4335 $ 0.10 A4335 U7 $ 0.50 A4353 U7 $ 5.40 A4362 $ 0.56 A4365 $ 1.50 A4402 $ 0.90 A4421 $ 1.20 A4554 $ 0.19 A4580 $ 28.00 A4580 U7 $ 39.00 A4580 U8 $ 55.00 A4606 $ 30.00 A4606 U7 $ 80.00 A4617 $ 2.40 A4618 NU $ 98.00 A4627 $ 18.00 A4628 $ 4.00 A4629 $ 3.00 A4927 $ 8.00 A6208 $ 9.24 A6501 $150.00 A6503 $ 53.00 A6504 RT, LT, 50 $ 71.00 A6505 RT, LT, 50 $ 22.00 A6506 RT, LT, 50 $ 71.00 A6509 $ 83.00 A6511 $107.50 A6512 U9 $ 80.00 A6512 U7 $ 24.50 A6512 U8 $ 36.50 A6512 $ 7.50 A9900 $ 8.15 B4164 $ 67.00 B4168 $ 67.00 B4172 $ 67.00 B4176 $ 67.00 B4178 $ 67.00 B4180 $ 67.00 B4184 $ 67.00 B4186 $ 67.00 B4189 $ 67.00 B4193 $ 67.00 B4197 $ 67.00 B4199 $ 67.00 B4216 $ 67.00 B5000 $ 67.00 B5100 $ 67.00 B5200 $ 67.00 B9998 U8 $ 90.84 E0144 RR $ 16.24 E0144 NU $162.40 E0241 U7 $ 16.50 E0241 U9 $ 21.00 E0241 NU $ 15.50 E0241 U8 $ 17.00 E0241 U4 $ 18.00 E0315 NU $ 17.00 E0445 RR $ 35.00 E0445 NU $395.00 E0602 $ 25.00 E0710 $ 15.50 E1035 NU $579.00 E1060 NU $770.00 E1060 RR $ 65.00 E1223 NU $505.00 E1223 RR $ 45.00 E1224 NU $580.00 E1224 RR $ 56.00 E1228 NU $129.00 E1231 NU $670.00 E1340 $ 6.25 E1399 U8 $ 49.00 E1399 U7 $ 20.00 E1800 NU RT, LT, 50 $695.00 K0009 NU $780.00 K0014 NU $780.00 K0014 U7 $925.00 K0108 U8 $167.00 K0108 UB $ 70.00 K0108 U9 $200.00 K0108 NU $250.00 K0108 U7 $160.00 L1200 $790.00 L3060 RT, LT, 50 $ 55.00 L3201 RT, LT, 50 $ 19.50 L3202 RT, LT, 50 $ 19.50 L3203 RT, LT, 50 $ 19.50 L3204 RT, LT, 50 $ 19.50 L3206 RT, LT, 50 $ 19.50 L3207 RT, LT, 50 $ 19.50 L3215 $ 39.00 L3216 $ 39.00 L3217 $ 39.00 L3219 $ 39.00 L3221 $ 39.00 L3222 $ 39.00 L3224 RT, LT, 50 $ 19.50 L3225 RT, LT, 50 $ 19.50 L3230 $ 39.00 L3250 RT, LT, 50 $ 19.50 L7520 $ 7.50 L8190 $ 53.50 L8200 $ 53.50 L8210 RT, LT, 50 $ 79.00 L8500 $225.00 L8501 $ 75.00 S8189 U7 $ 6.00 S8189 U8 $ 14.00 S8424 RT, LT, 50 $ 24.50 S8428 RT, LT, 50 $ 6.00 S8490 $ 0.19 S8999 $ 40.00 S8999 NU $225.00 V2521 VP, RT, LT, 50 $ 90.00 V2522 VP, RT, LT, 50 $ 90.00 V2523 VP, RT, LT, 50 $ 90.00 V5014 $ 45.00 V5160 $225.00 V5265 $ 15.00 V5266 $ 1.25 Medical Assistance Bulletins will be issued to providers of durable medical equipment, medical supplies, vision supplies and hearing supplies that include a cross walk of all the local procedure codes that are being end-dated, the National procedure codes and modifiers, as applicable, that are replacing them and any specific prior authorization requirements.
Prior Authorization Requirements
As set forth as follows, the following National procedure codes require prior authorization for dates of service on or after December 12, 2005. In some instances, and as noted as follows, these prior authorization requirements are for items, services or procedures that did not previously require prior authorization.
In some instances durable medical equipment, medical supplies, vision supplies and hearing supplies did not previously require prior authorization. Section 443.6(a) of the Public Welfare Code (code) (62 P. S. § 443.6(a)), regarding reimbursement for certain medical assistance items and services, sets forth that in order to receive payment for items or services in subsection (b), the provider must secure authorization prior to actually providing the items or services. As noted as follows, effective for dates of service on or after December 12, 2005, the National procedure code requires prior authorization.
The following National procedure codes are for prostheses and orthoses and are therefore subject to prior authorization under section 443.6(b)(1) of the code as amended by the act of July 7, 2005 (P. L. 177 No. 42):
L0100 Cranial orthosis (helmet), with or without soft interface, molded to patient model.
Note: This National procedure code did not previously require prior authorization.L0110 Cranial orthosis (helmet), with or without soft-interface, nonmolded.
Note: This National procedure code did not previously require prior authorization.L0976 LSO, full corset.
Note: This National procedure code did not previously require prior authorization.L1200 Thoracic-lumbar-sacral-orthosis (tlso), inclusive of furnishing initial orthosis only.
L1810 RT, LT, 50 Knee orthosis, elastic with joints, prefabricated, includes fitting and adjustment.
Note: This National procedure code did not previously require prior authorization.L8190 Gradient compression stocking, waist length, 18-30 mmhg, each.
L8195 Gradient compression stocking, waist length, 30-40 mmhg, each.
Note: This National procedure code did not previously require prior authorization.L8200 Gradient compression stocking, waist length, 40-50 mmhg, each.
L8210 RT, LT, 50 Gradient compression stocking, custom made.
L8500 Artificial larynx, any type.
Note: The local code that L8500 is replacing did not require prior authorization. The National procedure code L8500 requires prior authorization.L8501 Tracheostomy speaking valve.
V5242 RT, LT, 50 Hearing aid, analog, monaural hearing aid, CIC (completely in the ear canal).
Note: The local procedure code that V5242 is replacing did not require prior authorization. The National procedure code V5242 requires prior authorization.V5243 RT, LT, 50 Hearing aid, analog, monaural hearing aid, ITC (in the canal).
Note: The local procedure code that V5243 is replacing did not require prior authorization. The National procedure code V5243 requires prior authorization.V5248 Hearing aid, analog, binaural, CIC (completely in the ear canal).
Note: The local procedure code that V5248 is replacing did not require prior authorization. The National procedure code V5248 requires prior authorization.V5249 Hearing aid, analog, binaural, ITC (in the canal).
Note: The local procedure code that V5249 is replacing did not require prior authorization. The National procedure code V5249 requires prior authorization.The following National procedure codes for appliances or equipment require prior authorization under section 443.6(b)(2) of the code either because the item costs more than $600 or because the item costs $600 or less and the Department has determined to require prior authorization:
E0144 NU Walker, enclosed, 4 sided frame, rigid or folding wheeled, with posterior seat.
E1035 NU Multi-positional patient transfer system with integrated seat operated by caregiver.
E1060 NU Fully reclining wheelchair; detachable arms, desk or full length, swingaway detachable, elevating legrests.
E1223 NU Wheelchair with detachable arms and foot rests.
E1224 NU Wheelchair with detachable arms, elevating leg rests.
E1228 NU Special back height for wheelchair.
E1231 NU Wheelchair, pediatric size, tilt-n-space, rigid, adjustable with seating system.
E1250 NU Lightweight wheelchair; fixed full-length arms, swingaway detachable footrests.
Note: This National procedure code did not previously require prior authorization.E1270 NU Lightweight wheelchair; fixed full-length arms, swingaway detachable, elevating legrests.
Note: This National procedure code did not previously require prior authorization.E1298 NU Special wheelchair seat depth and/or width, by construction.
Note: This National procedure code did not previously require prior authorization.E1800 NU Dynamic adjustable elbow extension/flexion device, includes soft interface material.
K0009 NU Other manual wheelchair/base.
K0014 NU Other motorized power wheelchair base.
K0108 NU Wheelchair component or accessory, not otherwise specified.
The following National procedure codes are for oxygen and related equipment and are subject to prior authorization, as set forth in section 443.6(b)(4) of the code:
E0424 RR Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask and tubing.
Note: This National procedure code did not previously require prior authorization.E0439 RR Stationary liquid oxygen system, rental; includes container, contents, regulator, flow meter, humidifier, nebulizer, cannula or mask and tubing.
Note: This National procedure code did not previously require prior authorization.E0445 NU Oximeter device for measuring blood oxygen levels noninvasively.
E1390 RR Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate.
Note: This National procedure code did not previously require prior authorization.S8999 NU Resuscitation bag (for use by patient on artificial respiration during power failure or other catastrophic event).
The following National procedure codes are for orthopedic shoes or other supportive devices for the feet and are therefore subject to prior authorization under section 443.6(b)(6) of the code:
L3060 RT, LT, 50 Foot, arch support, removable, premolded, longitudinal/ metatarsal, each.
L3140 Foot, abduction rotation bar, including shoes.
Note: This National procedure code did not previously require prior authorization.L3201 RT, LT, 50 Orthopedic shoe, oxford with supinator or pronator, infant.
L3202 RT, LT, 50 Orthopedic shoe, oxford with supinator or pronator, child.
L3203 RT, LT, 50 Orthopedic shoe, oxford with supinator or pronator, junior.
L3204 RT, LT, 50 Orthopedic shoe, hightop with supinator or pronator, infant.
L3206 RT, LT, 50 Orthopedic shoe, hightop with supinator or pronator, child.
L3207 RT, LT, 50 Orthopedic shoe, hightop with supinator or pronator, junior.
L3215 Orthopedic footwear, ladies shoes, oxford.
L3216 Orthopedic footwear, ladies shoes, depth inlay.
L3217 Orthopedic footwear, ladies shoes, hightop, depth inlay.
L3219 Orthopedic footwear, mens shoes, oxford.
L3221 Orthopedic footwear, mens shoes, depth inlay.
L3222 Orthopedic footwear, mens shoes, hightop, depth inlay.
L3224 RT, LT, 50 Orthopedic footwear, women's shoe, oxford, used as an integral part of a brace (orthosis).
L3225 RT, LT, 50 Orthopedic footwear, men's shoe, oxford, used as an integral part of a brace (orthosis).
L3230 Orthopedic footwear, custom shoes, depth inlay.
L3250 RT, LT, 50 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each.
The following National procedure code is subject to prior authorization as authorized in section 443.6(b)(7) of the code:
V5160 Dispensing fee, bilateral.
Services rendered on or after December 12, 2005, must be billed using the National procedure code and modifiers, if applicable.
Fiscal Impact
The conversion from local to National procedure codes is anticipated to be budget neutral and, therefore, these changes will have no fiscal impact.
Public Comment
Interested persons are invited to submit written comments regarding this notice 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 within 30 days will be reviewed and considered for any subsequent revisions of the notice.
Persons with a disability who require an auxiliary aid or service may submit comments using the AT&T Relay Services at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-NOT-453. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 05-2279. Filed for public inspection December 9, 2005, 9:00 a.m.]
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