NOTICES
Medical Assistance Program Fee Schedule Revisions; 2008 HCPCS Updates; Prior Authorization Requirements
[39 Pa.B. 3234]
[Saturday, June 27, 2009]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 July 13, 2009.
Fee Schedule Revisions
The Department is adding and end-dating procedure codes as a result of implementing the 2008 updates made by the Centers for Medicare and Medicaid Services (CMS) to the Healthcare Common Procedure Coding System (HCPCS). The Department is also end-dating other procedure codes, including some codes previously end-dated by CMS. Additionally, the Department is adding procedure codes, and procedure code and modifier combinations, to the MA Program Fee Schedule as a result of significant program exception requests. Finally, as set forth as follows, some of the procedure codes being added to the MA Program Fee Schedule will require prior authorization.
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.
The following procedure codes are being added to the MA Program Fee Schedule as a result of the 2008 HCPCS:
Procedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and Modifiers01935 01936 20555 20555(SG) 21073 21073 (SG) 22206 22206 (80) 22207 22207 (80) 22208 22208 (80) 24357 24357 (SG) 24358 24358 (SG) 24359 24359 (SG) 27267 27268 27268 (80) 27269 27269 (80) 27416 27416 (SG) 27726 27726 (SG) 27767 27768 27768 (SG) 27769 27769 (SG) 29828 29828 (SG) 29828 (80) 29904 29904 (SG) 29904 (80) 29905 29905 (SG) 29905 (80) 29906 29906 (SG) 29906 (80) 29907 29907 (SG) 29907 (80) 32421 32421 (SG) 32422 32422 (SG) 32550 32550 (SG) 32551 32551 (SG) 32560 32560 (SG) 33257 33257 (80) 33258 33258 (80) 33259 33259 (80) 33864 33864 (80) 35523 35523 (80) 36593 41019 41019 (SG) 49203 49203 (80) 49204 49204 (80) 49205 49205 (80) 49440 49440 (SG) 49441 49441 (SG) 49442 49442 (SG) 49446 49446 (SG) 49450 49450 (SG) 49451 49451 (SG) 49452 49452 (SG) 49460 49460 (SG) 49465 50385 50385 (SG) 50386 50386 (SG) 51100 51101 51102 51102 (SG) 52649 52649 (SG) 55920 55920 (SG) 57285 57285 (SG) 57285 (80) 57423 57423 (SG) 57423 (80) 58570 58570 (SG) 58570 (80) 58571 58571 (SG) 58571 (80) 58572 58572 (SG) 58572 (80) 58573 58573 (SG) 58573 (80) 60300 67041 67041 (SG) 67041 (80) 67042 67042 (SG) 67042 (80) 67043 67043 (SG) 67043 (80) 67113 67113 (SG) 67113 (80) 67229 67229 (SG) 68816 68816 (SG) 75557 75557 (26) 75557 (TC) 75559 75559 (26) 75559 (TC) 75561 75561 (26) 75561 (TC) 75563 75563 (26) 75563 (TC) 80047 82610 83993 84704 86356 87500 87809 90681 90696 95981 95982 96125 99477 A5083 A7027 A7028 A7029 A9155 B4087 B4088 E0856 (NU) E0856 (RR) E2312 (NU) E2313 (NU) E2397 (NU) J7347 J7349 L3925 L3927 L3929 L3931 L7611 L7612 L7613 L7614 L7621 L7622 S2066 S2066 (80) S2067 S2067 (80) S9152 The following procedure codes are being added to the MA Program Fee Schedule as a result of significant program exception requests:
Procedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and Modifiers78709 78709 (TC) 78709 (26) 80050 80416 80417 90875 97532 A6412 B4224 E0482 E0482 (RR) J1642 S3645 The following procedure codes are being end-dated from the MA Program Fee Schedule either as a result of the 2008 HCPCS updates or because they were previously end-dated by CMS:
Procedure Codes
01905 24350 24351 24352 24354 24356 32000 32002 32019 32020 36550 43750 47719 49200 49201 51000 51005 51010 60001 67038 74350 75552 75553 75554 75555 78615 99271 99272 99273 99274 99275 99301 99302 99303 99311 99312 99313 A4534 B4086 E2618 G0298 G0299 J7345 L0960 L1855 L1858 L1870 L1880 L3800 L3805 L3810 L3815 L3820 L3825 L3830 L3835 L3840 L3845 L3850 L3855 L3860 L3907 L3910 L3916 L3918 L3920 L3922 L3924 L3926 L3928 L3930 L3932 L3934 L3936 L3938 L3940 L3942 L3944 L3946 L3948 L3950 L3952 L3954 L3985 L3986 Q0068 S2078 The Department is end-dating the following procedure codes from the MA Program Fee Schedule because they are services related to infertility treatment. Section 443.6(f) (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) prohibits the Department from paying a provider for any medical services, procedures or drugs related to infertility therapy:
Procedure Codes
58345 74440 74742 89300 89310 Q0115 The Department is end-dating the following procedure codes from the MA Program Fee Schedule because they are cosmetic surgical procedures. Sections 1126.54, 1141.59 and 1163.59 (relating to noncompensable services and items; noncompensable services; and items and outlier days) of 55 Pa. Code sets forth that payments will not be made for cosmetic surgery:
Procedure Codes
15780 15781 15782 15786 15787 15792 15793 15819 17340 17360 21120 21121 21122 21123 21137 21198 21270 30400 30410 30420 30430 30435 30450 54660 67900 69300 The following local procedure codes will be end-dated from the MA Program Fee Schedule due to the adoption of National codes:
Procedure Codes
W0081 W0082 W0083 W0161 W0162 W0164 W0166 W0167 W0168 W0169 W0170 W0184 W0185 W0186 W0187 W0300 W0301 W0315 W0710 W0711 W0712 W0713 W0714 W0734 W0735 W0974 W1751 W1807 W1809 W1810 W1811 W1812 W1813 W1814 W1815 W1816 W1817 W1818 W1845 W1846 W1847 W1869 W1870 W5997 W6004 W6052 W6058 W6059 W7003 W8995 W9066 W9310 W9635 W9991 W9992 W9993 W9994 W9995 X2830 X2912 X2934 X3154 X3649 X4289 X4693 X6483 X6781 Y7372 Y7375 Y7690 Y7696 Y9876 Y9897 Y9925 Z0052 Z0465 Z0467 Z0518 Z0528 Z0529 Z0535 Z0537 Z0540 Z0544 Z1971 Z2104 Z3063 Z4254 Z4375 Z4383 Z4464 Z4601 Z4627 Z4628 Z6001 Z6004 Z6006 Z8214 Z8250 Z8252 Z8372 Z8373 Z8379 Z8383 Z8384 Z8385 Z8388 Z8397 Z8414 Z8502 Z8558 Z8628 Z8743 Z9803 The Department is end-dating procedure code 91111 (gastrointestinal tract imaging, intraluminal (for example, capsule endoscopy), esophagus with physician interpretation and report) from the MA Program Fee Schedule because the use of this procedure is not the accepted standard of practice for the treatment or diagnosis of any condition.
The Department will be adding the following pricing modifiers to procedure codes currently on the MA Program Fee Schedule. The modifiers (SG) and (26) are being added to surgical services currently designated as inpatient services, but which can safely be performed in the Hospital Short Procedure Unit or the Ambulatory Surgical Center, or both, depending on the procedure:
Procedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and ModifiersProcedure Code
and Modifiers15821 (SG) 21127 (SG) 24346 (SG) 36522 (SG) 42890 (SG) 44376 (SG) 58555 (SG) 65880 (SG) 93510 (26) 93642 (SG) 93642 (26) The Department is increasing the MA Program fee for the following procedure code:
Procedure Code Description Current Fee MA Fee Effective July 13, 2009 95165 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) $2.88 $8.22 Effective for dates of services on and after July 13, 2009, procedure code 93642 must be billed with modifier (26) with the associated fee of $253.03 as noted:
Procedure Code Description Current Fee (Billing with No Modifier) MA Fee Effective July 13, 2009 (Billing with modifier 26) 93642 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters) $488.41 $253.03 Prior Authorization Requirements
The following procedure codes that are being added to the MA Program Fee Schedule are prosthesis and orthoses that require 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):
Procedure Code Procedure Description L9325 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, includes fitting and adjustment. L3927 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without joint/spring, extension/flexion (e.g. static or ring type), may include soft interface material, prefabricated, includes fitting and adjustment. L3929 Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment. L3931 Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment. L7611 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric. L7612 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric. L7613 Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric. L7614 Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric. L7621 Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined. L7622 Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined. The following procedure codes being added to the MA Program Fee Schedule are durable medical equipment (DME) and will require prior authorization, as authorized under § 443.6(b)(2) of the Code, as amended by the act of July 7, 2005 (P. L. 177, No. 42):
Procedure Code Procedure Description E0482 Cough stimulating device, alternating positive and negative airway pressure. E0856 (NU) Cervical traction device, cervical collar with inflatable air bladder. E2312 (NU) Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware. E2313 (NU) Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each. E2397 (NU) Power wheelchair accessory, lithium-based battery, each. Rentals of the following DME, which are being added to the MA Program Fee Schedule, will require prior authorization beginning with the first month of rental, as authorized under section 443.6(b)(3) of the Code, as amended by the act of July 7, 2005 (P. L. 177, No. 42):
Procedure Code Procedure Description E0482 (RR) Cough stimulating device, alternating positive and negative airway pressure. E0856 (RR) Cervical traction device, cervical collar with inflatable air bladder. The following procedure codes being added to the MA Program Fee Schedule will require prior authorization, as authorized under § 443.6(b)(7) of the Code, as amended by the act of July 7, 2005 (P. L. 177, No. 42):
Procedure Code Procedure Description A9155 Artificial saliva, 30 ml. J1642 Injection, heparin sodium (heparin lock flush), per 10 units. 75557 Cardiac magnetic resonance imaging for morphology and function without contrast material 75559 Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging. 75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences. 75563 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging. Fiscal Impact
The estimated cost for Fiscal Year (FY) 2009-2010 is $2.774 million ($0.988 million in State funds). The annualized cost for FY 2010-2011 is $3.170 million ($1.295 million in State funds). These State fund estimates are based on the increased Federal Medical Assistance Percentages as determined under the American Recovery and Reinvestment Act (ARRA) of 2009 (42 U.S.C.A. § 5301).
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 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 Pennsylvania AT&T Relay Service (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-NOT-605. (1) General Fund; (2) Implementing Year 2008-09 is $0; (3) 1st Succeeding Year 2009-10 is $0.988 M; 2nd Succeeding Year 2010-11 is $1.295 M; 3rd Succeeding Year 2011-12 is $1.473 M; 4th Succeeding Year 2012-13 is $1.473 M; 5th Succeeding Year 2013-14 is $1.473 M; (4) 2007-08 Program--$593.992 M; 2006-07 Program--$671.472 M; 2005-06 Program--$945.9550 M; (7) Medical Assistance--Outpatient; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 09-1164. Filed for public inspection June 26, 2009, 9:00 a.m.]
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