NOTICES
Medical Assistance Program Fee Schedule Revisions; 2006 HCPCS Updates; Prior Authorization Requirements
[36 Pa.B. 7764]
[Saturday, December 16, 2006]The Department of Public Welfare (Department) announces 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 2006 updates made by the Centers for Medicare and Medicaid Services (CMS) to the Healthcare Common Procedure Coding System (HCPCS). The 2006 HCPCS codes are effective for dates of service on and after January 2, 2007.
Fees for the new procedure codes will be published in a medical assistance bulletin that will be issued to all providers.
Procedure codes being added to the MA Program Fee Schedule as a result of the 2006 HCPCS updates which are effective and compensable for dates of service as of January 2, 2007.
Procedure Code Procedure Code Procedure Code Procedure Code and Modifiers and Modifiers and Modifiers and Modifiers A4233 L3961 22525 80195 A4234 L3967 32503 82271 A4235 L3971 32503 (80) 82272 A4236 L3973 32504 83631 A4363 L3975 32504 (80) 83695 A4411 L3976 33507 83700 A4412 L3977 33507 (80) 83701 A4604 L3978 33768 83900 A5120 L5703 33768 (80) 83901 A5512 L5971 33880 83907 A5513 L6677 33880 (80) 83908 A6457 L7400 33881 83909 A6513 L7401 33881 (80) 86200 A6530 L7402 33883 86355 A6531 L7403 33883 (80) 86357 A6532 L7404 33884 86367 A6533 L7405 33884 (80) 86923 A6534 L8623 33886 87209 A6535 L8624 33886 (80) 87900 A6536 S0625 33889 88333 A6537 S2075 33889 (80) 88333 (26) A6538 S2075 (80) 33891 88333 (TC) A6539 S2075 (SG) 33891 (80) 88334 A6540 S2076 33925 88334 (26) A6541 S2076 (80) 33925 (80) 88334 (TC) A6543 S2076 (SG) 33926 88384 A6544 S2077 33926 (80) 88385 B4185 S2077 (80) 36598 88386 E0705 (NU) S2078 37184 (SG) 90649 E0705 (RR) S2078 (80) 37185 90714 E0911 (NU) S2078 (SG) 37186 90736 E0911 (RR) S2079 37187 90760 E1392 (RR) S2079 (80) 37187 (SG) 90761 E2207 (NU) S2079 (SG) 37188 90765 E2207 (RR) S3626 37188 (SG) 90766 E2208 (NU) 01965 44180 90767 E2208 (RR) 01966 44180 (80) 90768 E2209 (NU) 15110 44180 (SG) 90772 E2209 (RR) 15110 (SG) 44186 90773 E2210 (NU) 15111 44186 (80) 90774 E2211 (NU) 15115 44186 (SG) 90775 E2212 (NU) 15115 (SG) 44187 91022 E2213 (NU) 15116 44187 (80) 91022 (26) E2214 (NU) 15130 44187 (SG) 91022 (TC) E2215 (NU) 15130 (SG) 44188 92626 E2216 (NU) 15131 44188 (80) 92627 E2217 (NU) 15135 44188 (SG) 92630 E2218 (NU) 15135 (SG) 44213 92633 E2219 (NU) 15136 44213 (80) 95865 E2220 (NU) 15150 44227 95865 (26) E2221 (NU) 15150 (SG) 44227 (80) 95865 (TC) E2222 (NU) 15151 44227 (SG) 95866 E2223 (NU) 15152 45395 95866 (26) E2224 (NU) 15155 45395 (80) 95866 (TC) E2225 (NU) 15155 (SG) 45395 (SG) 96101 E2226 (NU) 15156 45397 96101 (U8) E2371 (NU) 15157 45397 (80) 96101 (U7) E2372 (NU) 15170 45397 (SG) 96101 (AH) L0491 15170 (SG) 45400 96101 (TF) L0492 15171 45400 (80) 96101 (UB) L0621 15175 45400 (SG) 96101 (TG) L0622 15175 (SG) 45402 96116 L0623 15176 45402 (80) 96118 L0624 15300 45402 (SG) 96118 (UB) L0625 15300 (SG) 45990 96401 L0626 15301 45990 (SG) 96402 L0627 15320 46505 96409 L0628 15320 (SG) 46710 96411 L0629 15321 46710 (80) 96413 L0630 15330 46710 (SG) 96415 L0631 15330 (SG) 46712 96416 L0632 15331 46712 (80) 96417 L0633 15335 50250 96521 L0634 15335 (SG) 50250 (80) 96522 L0635 15336 50382 96523 L0636 15340 50382 (SG) 99300 L0637 15340 (SG) 50384 99304 L0638 15341 50384 (SG) 99305 L0639 15360 50387 99306 L0640 15360 (SG) 50387 (SG) 99307 L0859 15361 50389 99308 L2034 15365 50389 (SG) 99309 L2387 15365 (SG) 50592 99310 L3671 15366 50592 (80) 99318 L3672 15420 50592 (SG) 99324 L3673 15420 (SG) 57295 99325 L3702 15421 57295 (80) 99326 L3763 15430 58110 99327 L3764 15430 (SG) 75956 99328 L3765 15431 75957 99334 L3766 22010 75958 99335 L3905 22010 (SG) 75959 99336 L3913 22015 76376 99337 L3919 22015 (SG) 76377 L3921 22523 77421 L3933 22523 (SG) 77421 (26) L3935 22524 77421 (TC) 22524 (SG) 77422 77423 Procedure codes being end-dated from the MA Program fee schedule as a result of the 2006 HCPCS updates and which will not be compensable for services provided after January 1, 2007:
Procedure Codes
A5119 G0213 K0074 K0637 L8620 32525 82273 96520 A5511 G0214 K0075 K0639 Q4055 33918 83715 96530 A6551 G0215 K0076 K0640 01964 33919 83716 97020 B4184 G0216 K0078 K0642 15342 37720 86064 97520 B4186 G0217 K0102 K0644 15343 37730 86379 96520 E0953 G0218 K0104 K0645 15350 42325 86587 96530 E0954 G0220 K0106 K0646 15351 42326 90782 97020 E0972 G0221 K0618 K0647 15810 43638 90784 97520 E0996 G0222 K0619 K0648 15811 43639 90871 96520 E1000 G0234 K0620 K0649 16010 44200 96100 96530 E1001 G0296 K0628 K0671 16015 44201 96115 97020 E1025 G0356 K0629 L1750 21493 76375 96117 97520 E1026 G0363 K0630 L3963 21494 78160 96400 96520 E1027 K0064 K0631 L8190 31585 78162 96408 96530 G0210 K0066 K0634 L8195 31586 78170 96410 97020 G0211 K0067 K0635 L8200 32520 78172 96412 G0212 K0068 K0636 L8210 32522 78455 96414 Prior Authorization Requirements
The following new 2006 HCPCS procedure codes are for items of prostheses and orthoses and therefore require prior authorization under section 443.6(b)(1) of the Public Welfare Code (code) (62 P. S. § 443.6(b)(1)), as amended by the act of July 7, 2005 (P. L. 177, No. 42):
Procedure Code Procedure Description L0491 TLSO, sagittal-coronal control, modular segmented spinal system, two reigid 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 and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment L0492 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 symphysis pubis to the xyphoid, soft liner, restricts gross trunk motion in the Sagittal and Coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment L0621 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment L0622 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated. L0623 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment L0624 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated L0625 Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abd.design, shoulder straps, stays, prefabricated, includes fitting and adjust. L0626 Lumbar orthosis, sagittal control, with rigid posterior panel, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abd.design, shoulder straps, stays, prefabri- cated, includes fitting and adjust. L0627 Lumbar orthosis, sagittal control, with rigid anterior and posterior panel, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abd.design, shoulder straps, stays, prefabricated, includes fitting and adjust. L0628 Lumbar orthosis, flexible, provides lumbar-sacral support, posterior extends from sacro- coccygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abd.design, shoulder straps, stays, prefabricated, includes fitting and adjust. L0629 Lumbar orthosis, flexible, provides lumbar-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, pendulous abd.design, shoulder straps, custom fabricated. L0630 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment L0631 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, pendulous abdomen design, prefabri- cated, includes fitting and adjustment L0632 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated L0633 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment L0634 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intravertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated L0635 Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment L0636 Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abd.design, custom fabricated L0637 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment L0638 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/ panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated L0639 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment L0640 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated L0859 Addition to halo procedure, MRI compatible systems, rings and pins, any material L2034 Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated L2387 Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint L3671 Shoulder orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3672 Shoulder orthosis, adbduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3673 Shoulder orthosis, adbduction positioning (airplane design), thoracic component and support bar, includes nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3702 Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3763 Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, inlcudes fitting and adjustment L3764 Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3765 Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3766 Elbow wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3905 Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated includes fitting and adjustment L3913 Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3919 Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3921 Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3933 Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment L3935 Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment L3961 Shoulder elbow wrist hand orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3967 Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3971 Shoulder elbow wrist hand orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment. L3973 Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3975 Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment. L3976 Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3977 Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment. L3978 Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L5703 Ankle, symes, molded to patient model, socket without solid ankle cushion heel L5971 All lower extremity prosthesis, solid ankle cushion heel (SACH) foot, replacement only L6677 Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow L7400 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal) L7401 Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal) L7402 Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal) L7403 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material L7404 Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material L7405 Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material L8623 Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each L8624 Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each Fiscal Impact
The estimated cost for Fiscal Year 2006-2007 is $0.764 million ($0.348 million in State funds). The estimated cost for Fiscal Year 2007-2008 is $2.291 million ($1.050 million in State funds).
Public Comment
Interested persons are invited to submit written comments regarding this notice to the Department at the following address: Department of Public Welfare, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, 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 AT&T Relay Service, (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-NOT-492. (1) General Fund; (2) Implementing Year 2006-07 is $348,000; (3) 1st Succeeding Year 2007-08 is $1,050,000; 2nd Succeeding Year 2008-09 is $1,052,000; 3rd Succeeding Year 2009-10 is $1,052,000; 4th Succeeding Year 2010-11 is $1,052,000; 5th Succeeding Year 2011-12 is $1,052,000; (4) 2005-06 Program--$945,950,000; 2004-05 Program--$842,991,000; 2003-04 Program--$677,979,000; (7) Medical Assistance-Outpatient; (8) recommends adoption. Funds are included in the 2006-07 budget for this purpose.
[Pa.B. Doc. No. 06-2479. Filed for public inspection December 15, 2006, 9:00 a.m.]
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