NOTICES
DEPARTMENT OF
PUBLIC WELFARE
Medical Assistance Program Fee Schedule Revisions; 2004 HCPCS Updates; Prior Authorization Requirements
[35 Pa.B. 803] 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 2004 updates made by the Centers for Medicare and Medicaid Services to the Healthcare Common Procedure Coding System (HCPCS). The 2004 HCPCS codes are effective for dates of service on and after February 7, 2005.
In addition to the HCPCS updates, the Department is adding procedure codes 35500, L8509 and P9017 with effective dates of service on and after February 7, 2005. Procedure codes 35500 and P9017 are being added due to significant Program Exception requests. Procedure code L8509 is being added due to the 2004 addition of procedure code L8511 which requires procedure code L8509 to be billed as a primary code.
Fees for the added procedure codes will be published in a MA Bulletin that will be issued to all providers.
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 section 443.6(b)(2) of the Public Welfare Code (code) (62 P. S. § 443.6(b)(2)) concerning reimbursement for certain MA items and services:
E0140 NU Walker, with trunk support, adjustable or fixed height, any type E0248 NU Transfer bench, heavy duty, for tub or toilet with or without commode opening E0562 NU Humidifier, heated, used with positive airway pressure device E0637 NU Combination sit to stand system, any size, with seat lift feature, with or without wheels E0638 NU Standing frame system, any size, with or without wheels E0955 NU Wheelchair accessory, headrest, cushioned, prefabricated, including fixed mounting hardware, each E0957 NU Wheelchair accessory, medial thigh support, prefabricated, including fixed mounting hardware, each E0983 NU Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control E0984 NU Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control E0985 NU Wheelchair accessory, seat lift mechanism E1002 NU Wheelchair accessory, power seating system, tilt only E1003 NU Wheelchair accessory, power seating system, recline only, without shear reduction E1004 NU Wheelchair accessory, power seating system, recline only, with mechanical shear reduction E1005 NU Wheelchair accessory, power seating system, recline only, with power shear reduction E1006 NU Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction E1007 NU Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction E1008 NU Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction E1010 NU Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, each E1028 NU Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory E1029 NU Wheelchair accessory, ventilator tray, fixed E1030 NU Wheelchair accessory, ventilator tray, gimbaled E2201 NU Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches E2202 NU Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches E2203 NU Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches E2204 NU Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches E2310 NU Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch and fixed mounting hardware E2311 NU Power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch and fixed mounting hardware E2320 NU Power wheelchair accessory, hand or chin control interface, remote joystick or touchpad, proportional, including all related electronics and fixed mounting hardware E2321 NU Power wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch and fixed mounting hardware E2322 NU Power wheelchair accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch and fixed mounting hardware E2325 NU Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch and manual swingaway mounting hardware E2326 NU Power wheelchair accessory, breath tube kit for sip and puff interface E2327 NU Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch and fixed mounting hardware E2328 NU Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware E2329 NU Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array and fixed mounting hardware E2330 NU Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array and fixed mounting hardware E2340 NU Power wheelchair accessory, nonstandard seat frame width, 20-23 inches E2341 NU Power wheelchair accessory, nonstandard seat frame width, 24-27 inches E2342 NU Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches E2343 NU Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches E2351 NU Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface E2361 NU Power wheelchair accessory, 22nf sealed lead acid battery, each, (such as, gel cell, absorbed glassmat) E2363 NU Power wheelchair accessory, group 24 sealed lead acid battery, each (such as, gel cell, absorbed glassmat) E2366 NU Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or nonsealed, each E2367 NU Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or nonsealed, each K0618 TLSO, sagittal-coronal 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 symphsis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment K0619 TLSO, sagittal-coronal 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 symphsis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment L0112 Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated L0861 Addition to halo procedure, replacement liner/interface material L1831 Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment L1907 AFO, supramalleolar with straps, with or without interface/pads, custom fabricated L1951 Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment L1971 Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment L5673 Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism L5679 Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism L5681 Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679) L5683 Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679) The following new HCPCS procedure codes are subject to prior authorization as authorized under section 443.6(b)(7) of the code: E2402 RR Negative pressure wound therapy electrical pump, stationary or portable G0296 PET imaging, full and partial ring PET scanner only, for restaging of previously treated thyroid cancer of follicular cell origin following negative I-131 whole body scan V2121 Lenticular lens, per lens, single V2221 Lenticular lens, per lens, bifocal V2321 Lenticular lens, per lens, trifocal V2782 Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens V2783 Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens V2784 Lens, polycarbonate or equal, any index, per lens The following new HCPCS procedure code is for a prosthesis and therefore subject to prior authorization under section 443.6(b)(1) of the code: L8509 Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type
Procedure Codes Being Added to the Fee Schedule as a Result of the 2004 Updates and Additions Which are Effective and Compensable for Dates of Service as of February 7, 2005
PROCEDURE CODE
and ModifiersPROCEDURE CODE
and ModifiersPROCEDURE CODE
and ModifiersPROCEDURE CODE
and Modifiers20982
SG, 80
21685
SG, 80
22532
SG, 80
22533
SG, 80
22534
80
31632 31633 34805
80
35510
80
35512
80
35522
80
35525
80
35697
80
36555
SG, RT, LT, 50
36556
SG, LT, RT, 50
36557
SG, LT, RT, 5036558
SG, RT, LT, 50
36560
SG, RT, LT, 50
36561
SG, RT, LT, 50
36563
SG, RT, LT, 5036565
SG, RT, LT, 50
36566
SG, RT, LT, 50
36568
SG, RT, LT, 50
36569
SG, RT, LT, 5036570
SG, RT, LT, 50
36571
SG, RT, LT, 50
36575
SG, RT, LT, 50
36576
SG, RT, LT, 5036578
SG, RT, LT, 50
36580
SG, RT, LT, 50
36581
SG, RT, LT, 50
36582
SG, RT, LT, 5036583
SG, RT, LT, 50
36584
SG, RT, LT, 50
36585
SG, RT, LT, 50
36589
SG, RT, LT, 5036590
SG, RT, LT, 50
36595
SG, RT, LT, 50
36596
SG, RT, LT, 50
36597
SG, RT, LT, 5036838
SG, RT, LT, 50
37765
SG, RT, LT, 50
37766
SG, RT, LT, 50
43237
SG
43238
SG
53500
SG
57425
SG, 80
59070
SG59072
SG
59074
SG, 80
59076
SG, 80
61537
80
61540
80
61566
80
61567
80
61863
80
61864
80
61867
80
61868
80
63101
80
63102
80
63103
80
64449
64517
SG
64681
SG
65780
SG, 80
65782
SG, 80
67912
SG, RT, LT, 5070557
26
70558
26
70559
26
75998
TC, 26
76082
TC, 26
76083
TC, 26
76514
LT, RT, TC, 26, 50
76937
TC, 26
76940
26
78804
TC, 26
79403
TC, 26
84156 84157 85055 85396 87269 87329 87660 88112
TC, 26
88361
TC, 2689220 89225 89230 89235 90655 90698 90715 90734 95991 97755 A4216 A4217 A4366 A4416 A4417 A4418 A4419 A4420 A4423 A4424 A4425 A4426 A4427 A4428 A4429 A4430 A4434 A6407 A6441 A6442 A6443 A6444 A6445 A6446 A6447 A6448 A6449 A6450 A6451 A6452 A6453 A6454 A6455 A6456 A6550 A6551 A7046
NU
A7520 A7521 A7522 A7524 A7525 A7526 E0140
NU, RR
E0190
NU
E0240
NUE0247
NU
E0248
NU
E0301
RR
E0302
RR
E0303
RR
E0304
RR
E0470
RR
E0471
RR
E0472
RR
E0561
NU, RR
E0562
NU, RR
E0637
NU, RR
E0638
NU, RR
E0675
RR
E0955
NU,RR
E0956
NU, RRE0957
NU, RR
E0960
NU, RR
E0981
NU
E0982
NU
E0983
NU, RR
E0984
NU, RR
E0985
NU, RR
E1002
NU, RR
E1003
NU, RR
E1004
NU, RR
E1005
NU, RR
E1006
NU, RRE1007
NU, RR
E1008
NU, RR
E1010
NU, RR, LT, RT, 50
E1028
NU, RR, LT, RT, 50
E1029
NU, RR
E1030
NU, RR
E1391
RR
E2201
NU, RRE2202
NU, RR
E2203
NU, RR
E2204
NU, RR
E2310
NU, RR
E2311
NU, RR
E2320
NU, RR
E2321
NU, RR
E2322
NU, RR
E2323
NU, RR
E2324
NU, RR
E2325
NU, RR
E2326
NU, RRE2327
NU, RR
E2328
NU, RR
E2329
NU, RR
E2330
NU, RR
E2340
NU, RR
E2341
NU, RR
E2342
NU, RR
E2343
NU, RR
E2351
NU, RR
E2360
NU, RR
E2361
NU, RR
E2362
NU, RRE2363
NU, RR
E2364
NU, RR
E2365
NU, RR
E2366
NU, RR
E2367
NU, RR
E2402
RR
G0296
TC, 26
G0297
SG, 80
G0298
SG, 80
G0299
SG, 80
G0300
SG, 80
K0552 K0601 K0602 K0603 K0604 K0605 K0618 K0619 K0620 L0112 L0861 L1831
LT, RT, 50
L1907
LT, RT, 50
L1951
LT, RT, 50
L1971
LT, RT, 50
L3031
LT, RT, 50
L3917
LT, RT, 50
L5673
LT, RT, 50
L5679
LT, RT, 50
L5681
LT, RT, 50
L5683
LT, RT, 50
L8511 L8512 L8513 L8514 P9051
SG
P9052
SG
P9053
SG
P9054
SG
P9055
SG
P9056
SG
P9057
SG
P9058
SG
P9059
SG
P9060
SG
V2121 V2221 V2321 V2782 V2783 V2784
Procedure Codes Being Added to the Fee Schedule as a Result of Additions Which are Effective and Compensable for Dates of Service as of February 7, 2005
PROCEDURE CODE
and ModifiersPROCEDURE CODE
and Modifiers35500 L8509 P9017
SG
Procedure Codes Being End Dated From the Fee Schedule as a Result of the Updates and Which Will Not Be Compensable for Services Provided After February 6, 2005
Procedure Codes
A4621 A6421 E0142 E0145 E0146 E0165 E0975 E0976 E0979 E0991 E0993 E1066 E1069 G0236 K0016 K0022 K0025 K0026 K0027 K0028 K0029 K0030 K0031 K0032 K0033 K0035 K0036 K0048 K0049 K0054 K0055 K0057 K0058 K0062 K0063 K0079 K0080 K0082 K0083 K0084 K0085 K0086 K0087 K0088 K0089 K0100 K0103 K0107 K0112 K0113 K0268 K0531 K0532 K0533 K0534 K0541 K0542 K0543 K0544 K0549 K0550 L1885 L2102 L2104 L2122 L2124 Q9920 Q9921 Q9922 Q9923 Q9924 Q9925 Q9926 Q9927 Q9928 Q9929 Q9930 Q9931 Q9932 Q9933 Q9934 Q9935 Q9936 Q9937 Q9938 Q9939 Q9940 Y9643 Y9644 Y9963 Y9964 Y9965 Y9920 Y9921 Y9923 Y9927 Y9929 Y9931 Y9937 Z0245 Z0978 Z0979 Z4250 Z4255 Z4256 Z4257 Z4258 Z4259 Z4260 Z4261 Z4263 Z4267 Z4268 Z4271 Z4272 Z4279 Z4461 Z4465 Z6002 Z9000 Z9001 00544 36533 36534 36535 47134 61862 76085 76490 89360 90659
Local Procedure Codes Being End Dated on the Fee Schedule and Replaced With New Procedure Codes as a Result of the 2004 HCPCS Updates
END DATE
FEB. 6, 2005
USE
FEB. 7, 2005
END DATE
FEB. 6, 2005
USE
FEB. 7, 2005
Y9643 E1029 Y9643 E1030 Y9644 E1029 Y9644 E1030 Y9663 E0240 Y9664 E0240 Y9665 E0240 Y9920 E0637 Y9920 E0638 Y9921 E0637 Y9921 E0638 Y9923 E0637 Y9923 E0638 Y9927 E0955 Y9929 E0955 Y9931 E0960 Y9937 A7520 Y9937 A7520 Y9937 A7521 Y9937 A7522 Z0245 E0247 Z0245 E0248 Z0978 E0190 Z0979 E0190 Z4250 A7520 Z4250 A7521 Z4250 A7522 Z4255 A7521 Z4256 A7521 Z4257 A7521 Z4261 A7520 Z4261 A7521 Z4261 A7522 Z4263 A7520 Z4263 A7521 Z4263 A7522 Z4267 A6447 Z4268 A6445 Z4271 A6445 Z4272 A6445 Z4279 A6445 Z4280 A6442 Z4280 A6445 Z4281 A6443 Z4281 A6446 Z4282 A6443 Z4282 A6446 Z4283 A6444 Z4283 A6447 Z4269 A6446 Z4270 A6446 Z4462 A6449 Z4463 A6449 Z9800 A4217 Z4461 A6448 Z4465 A6450 Z6002 P9017 Z9001 E0190 Z4258 A7520 Z4259 A7520 Z4260 A7520 Z4260 A7521 Z4260 A7522 Z9000 A4216 Z9000 A4217 Fiscal Impact
The estimated cost for Fiscal Year 2004-2005 is $0.555 million ($0.256 million in State funds). The estimated cost for Fiscal Year 2005-2006 is $2.220 million ($1.004 million in State funds).
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 revision of this notice.
Persons with a disability who require an auxiliary aid or service may submit comments using the AT&T Relay Services by calling (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-NOT-409. (1) General Fund; (2) Implementing Year 2004-05 is $256,000; (3) 1st Succeeding Year 2005-06 is $1,004,000; 2nd Succeeding Year 2006-07 is $1,007,000; 3rd Succeeding Year 2007-08 is $1,010,000; 4th Succeeding Year 2008-09 is $1,010,000; 5th Succeeding Year 2009-10 is $1,010,000; 2003-04 Program--$727,979,000; 2002-03 Program--$666,832,000; 2001-02 Program--$705,750,000; (7) Medical Assistance--Outpatient; (8) recommends adoption. The cost outlined above have been included in the General Appropriation Act of 2004 (Act 7A).
[Pa.B. Doc. No. 05-251. Filed for public inspection February 4, 2005, 9:00 a.m.]
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