NOTICES
DEPARTMENT OF PUBLIC WELFARE
Medical Assistance Program Fee Schedule Revisions; 2007 HCPCS Updates; Prior Authorization Requirements
[38 Pa.B. 1222]
[Saturday, March 8, 2008]The Department of Public Welfare (Department) announces changes to the Medical Assistance (MA) Program Fee Schedule and prior authorization requirements. These changes are effective for dates of service on and after March 15, 2008.
Fee Schedule Revisions
The Department is adding and end-dating procedure codes as a result of implementing the 2007 updates made by the Centers for Medicare and Medicaid Services to the Healthcare Common Procedure Coding System (HCPCS). The Department is also adding procedure codes, and procedure code and modifier combinations, to the MA Program Fee Schedule as a result of significant program exception requests.
Fees for the new procedure codes, and procedure code and modifier combinations, 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 2007 HCPCS updates which are effective and compensable for dates of service as of March 15, 2008.
Procedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and Modifiers00625 35303 67346 (SG) 77078 (26) 00626 35303 (80) 72291 (26) 77078 (TC) 15002 35304 72292 (26) 77079 15002 (SG) 35304 (80) 76776 77079 (26) 15003 35305 76776 (26) 77079 (TC) 15004 35305 (80) 76776 (TC) 77080 15004 (SG) 35306 76813 77080 (26) 15005 35306 (80) 76813 (26) 77080 (TC) 15731 35537 76813 (TC) 77081 15731 (SG) 35537 (80) 76814 77081 (26) 15830 35538 76814 (26) 77081 (TC) 15830 (80) 35538 (80) 76814 (TC) 77083 15830 (SG) 35539 76998 (26) 77083 (26) 15847 35539 (80) 77001 77083 (TC) 15847 (80) 35540 77001 (26) 77084 17311 35540 (80) 77001 (TC) 77084 (26) 17312 35637 77002 77084 (TC) 17313 35637 (80) 77002 (26) 77371 17314 35638 77002 (TC) 77372 17315 35638 (80) 77003 77373 19105 35883 77003 (26) 77435 19300 35883 (80) 77003 (TC) 82107 19300 (SG) 35884 77011 83698 19301 35884 (80) 77011 (26) 83913 19301 (SG) 37210 77011 (TC) 86788 19302 37210 (SG) 77012 86789 19302 (80) 44157 77012 (26) 87305 19302 (SG) 44157 (80) 77012 (TC) 87498 19303 44158 77013 (26) 87640 19303 (80) 44158 (80) 77014 87641 19303 (SG) 47719 77014 (26) 87653 19304 47719 (80) 77014 (TC) 87808 19304 (80) 48105 77021 91111 19304 (SG) 48105 (80) 77021 (26) 91111 (26) 19305 48548 77021 (TC) 91111 (TC) 19305 (80) 48548 (80) 77022 (26) 92025 19306 49324 77031 92025 (26) 19306 (80) 49324 (80) 77031 (26) 92025 (TC) 19307 49324 (SG) 77031 (TC) 94002 19307 (80) 49325 77032 94003 25109 49325 (80) 77032 (26) 94610 25109 (SG) 49325 (SG) 77032 (TC) 94644 25606 49326 77051 94645 25606 (SG) 49326 (80) 77051 (26) 94777 25607 49402 77051 (TC) 96040 25607 (80) 49402 (SG) 77052 A4461 25607 (SG) 49435 77052 (26) A4463 25608 49435 (80) 77052 (TC) A4600 25608 (80) 49436 77053 A8000 25608 (SG) 49436 (80) 77053 (26) A8001 25609 49436 (SG) 77053 (TC) A8002 25609 (80) 54865 77054 A8003 25609 (SG) 54865 (SG) 77054 (26) A8004 27325 55875 77054 (TC) D0273 27325 (80) 55875 (SG) 77055 D1206 27325 (SG) 55876 77055 (26) D1555 27326 55876 (SG) 77055 (TC) G0392 27326 (80) 56442 77056 G0392 (SG) 27326 (SG) 56442 (SG) 77056 (26) G0393 28055 57296 77056 (TC) G0393 (SG) 28055 (SG) 57296 (80) 77057 G0394 32998 57558 77057 (26) J7345 32998 (80) 57558 (SG) 77057 (TC) K0738 (RR) 32998 (SG) 58541 77058 L1001 33202 58541(80) 77058 (26) L3806 33203 58541 (SG) 77058 (TC) L3808 33254 58542 77059 L3915 33254 (80) 58542 (80) 77059 (26) L6611 33255 58542 (SG) 77059 (TC) L6624 33255 (80) 58543 77072 L6639 33256 58543 (80) 77072 (26) L6703 33256 (80) 58543 (SG) 77072 (TC) L6704 33265 58544 77073 L6706 33265 (80) 58544 (80) 77073 (26) L6707 33266 58544 (SG) 77073 (TC) L6708 33266 (80) 58548 77074 L6709 33675 58548 (80) 77074 (26) L7007 33675 (80) 58957 77074 (TC) L7008 33676 58957 (80) 77075 L7009 33676 (80) 58958 77075 (26) L8691 33677 58958 (80) 77075 (TC) Q4081 33677 (80) 64910 77076 T4543 33724 64910 (80) 77076 (26) 33724 (80) 64910 (SG) 77076 (TC) 33726 64911 77077 33726 (80) 64911 (80) 77077 (26) 35302 64911 (SG) 77077 (TC) 35302 (80) 67346 77078 Procedure codes being end-dated from the MA Program Fee Schedule as a result of the 2007 HCPCS updates and which will not be compensable for services provided after March 14, 2008:
Procedure Codes
15000 31708 76003 76355 L0110 L6808 15001 31710 76005 76360 L3902 L6809 15831 33200 76012 76362 L3914 L6825 17304 33201 76013 76370 L6700 L6830 17305 33245 76020 76393 L6705 L6835 17306 33246 76040 76394 L6710 L6840 17307 33253 76061 76400 L6715 L6845 17310 35381 76062 76778 L6720 L6850 19140 35507 76065 76986 L6725 L6855 19160 35541 76066 78704 L6730 L6860 19162 35546 76071 78715 L6735 L6865 19180 35641 76075 78760 L6740 L6867 19182 44152 76077 91060 L6745 L6868 19200 44153 76082 92573 L6750 L6870 19220 47716 76083 94656 L6755 L6872 19240 48005 76086 94657 L6765 L6873 21300 48180 76088 A4348 L6770 L6875 25611 49085 76090 A4359 L6775 L6880 25620 54152 76091 E0164 L6780 L7010 26504 54820 76092 E0166 L6790 L7015 27315 56720 76093 E0180 L6795 L7020 27320 57820 76094 E0701 L6800 L7025 28030 67350 76095 E0977 L6806 L7030 31700 75998 76096 L0100 L6807 L7035 Procedure codes being added by the Department to the MA Program Fee Schedule as a result of significant program exception requests, which are effective and compensable for dates of service as of March 15, 2008.
Procedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and Modifiers17111 59514 78608 95810 (TC) 17111 (SG) 59514 (80) 78608 (26) 95811 43644 59820 (U7) 78608 (TC) 95811 (26) 43644 (80) 69710 86361 95811 (TC) 43770 69710 (80) 92135 95930 43770 (80) 69710 (SG) 92135 (26) 95930 (26) 43771 69711 92135 (TC) 95930 (TC) 43771 (80) 69711 (80) 92250 99239 43772 69711 (SG) 92250 (26) A4231 43772 (80) 69714 92250 (TC) A4230 43773 69714 (SG) 95805 (26) C1300 43773 (80) 69715 95805 (TC) E0619 (RR) 43774 69715 (SG) 95807 (26) S3818 43774 (80) 69717 95807 (TC) S3819 59025 (26) 69717 (SG) 95808 (26) S3820 59025 (TC) 69718 95808 (TC) S3822 59409 69718 (SG) 95810 (26) S3823 Prior Authorization Requirements
The Department has determined that the following procedure codes currently on the MA Program Fee Schedule will require prior authorization, as authorized under section 443.6(b)(7) (relating to reimbursement for certain medical assistance items and services) of the act of June 13, 1967 (P. L. 31, No. 21) (62 P. S. §§ 101--1503) known as Public Welfare Code (code):
72159 Magnetic resonance angiography, spinal canal and contents, with or without contrast materials 72198 Magnetic resonance angiography, pelvis, with or without contrast materials 73225 Magnetic resonance angiography, upper extremity, with or without contrast materials 76936 Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation, compression of lesion and imaging) 78647 Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT) 78807 Radiopharmaceutical localization of inflammatory process; tomographic (SPECT) The following procedure codes that are being added to the MA Program Fee Schedule are prostheses and orthoses that 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).
L1001 Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting and adjustment L3806 Wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface material, straps, custom fabricated, includes fitting and adjustment L3808 Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment L3915 Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment L6611 Addition to upper extremity prosthesis, external powered, additional switch, any type L6624 Upper extremity addition, flexion/extension and rotation wrist unit L6639 Upper extremity addition, heavy duty feature, any elbow L6703 Terminal device, passive hand/mitt, any material, any size L6704 Terminal device, sport/recreational/work attachment, any material, any size L6706 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined L6707 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined L6708 Terminal device, hand, mechanical, voluntary opening, any material, any size L6709 Terminal device, hand, mechanical, voluntary closing, any material, any size L7007 Electric hand, switch or myoelectric controlled, adult L7008 Electric hand, switch or myoelectric, controlled, pediatric L7009 Electric hook, switch or myoelectric controlled, adult L8691 Auditory osseointegrated device, external sound processor, replacement The Department has determined that the following new procedure codes being added to the MA Program Fee Schedule will require prior authorization as authorized under § 443.6(b)(7) of the code:
Procedure Code Procedure Description C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (list separately in
addition to code for primary procedure)19300 Mastectomy for gynecomastia 19304 Mastectomy, subcutaneous 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components) 43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric band component only 43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band component only 43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric band component only 43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band and subcutaneous port components 69710 Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone 69711 Removal or repair of electromagnetic bone conduction hearing device in temporal bone 69714 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy 69715 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy 69717 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy 69718 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation The following procedure code being added to the MA Program Fee Schedule is durable medical equipment and will require prior authorization, as authorized under § 443.6(b)(3) of the code:
E0619 (RR) Apnea monitor, with recording feature
Fiscal Impact
The estimated cost for Fiscal Year 2007-2008 is $0.537 million ($0.254 million in State funds). The estimated cost for Fiscal Year 2008-2009 is $3.220 ($1.515 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-543. (1) General Fund:
MA-Outpatient (2) Implementing Year 2007-08 is $254,000 (3) 1st Succeeding Year 2008-09 is $1,515,000 2nd Succeeding Year 2009-10 is $1,515,000 3rd Succeeding Year 2010-11 is $1,515,000 4th Succeeding Year 2011-12 is $1,515,000 5th Succeeding Year 2012-13 is $1,515,000 (4) 2006-07 Program-- $671,472,000 2005-06 Program-- $945,950,000 2004-05 Program-- $842,991,000 (7) Medical Assistance Outpatient; (8) recommends adoption. Funds have been included in the budget to cover these increases.
[Pa.B. Doc. No. 08-420. Filed for public inspection March 7, 2008, 9:00 a.m.]
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