NOTICES
DEPARTMENT OF
PUBLIC WELFARE
Medical Assistance Program Fee Schedule Revisions Purpose of Notice
[40 Pa.B. 939]
[Saturday, February 13, 2010]The Department of Public Welfare (Department) announces changes to the Medical Assistance (MA) Program Fee Schedule. These changes are effective for dates of service on and after March 1, 2010.
Fee Schedule Revisions
The Department is making updates to the MA Program Fee Schedule in response to requests received from providers and clinical reviews conducted by Department staff related to standards of practice, provider type/specialties, places of service and procedure code/modifier combinations.
Procedure Code and Procedure Code/Modifier End-Dates and Additions
The Department is end-dating the following radiological procedure codes because the radiopharmaceutical administration costs are included in the technical component fee for the service:
79005
79101
79445The Department is end-dating the following diagnostic procedure codes because they are experimental procedures. MA regulations at 55 Pa. Code § 1141.59 (relatingto noncompensable services) set forth that payments will not be made for experimental procedures:
95060
95065The Department is end-dating the following computerized 3-D rendering procedure codes because the costs for these services are included in the technical component fee for the radiology service:
76976
76377The Department is end-dating the following procedure code for overnight oxygen saturation monitoring because the procedure is integral to the service being provided or included in the support component fee and should not be billed separately:
94762
The following radiological and diagnostic procedure codes will have the total component (no modifier) end-dated since the technical component fee for the service is included in the Diagnosis Related Group (DRG), Hospital Short Procedure Unit (SPU), the Ambulatory Surgical Center (ASC) or Special Treatment Room (STR) support component payment:
76001
93640
93641The following radiological procedure code will have the technical component (TC modifier) end-dated since the technical component fee for the service is included in the DRG, ASC/SPU or STR support component payment:
76001
The following surgical procedure codes will have the 80 modifier end-dated since the services do not require an assistant surgeon:
36561
58671
69710The following physical therapy procedure codes will have the SG modifier end-dated since they are non-surgical procedures and are not appropriate in an ASC/SPU:
97597
97598
97602The following surgical procedure codes will have the SU modifier end-dated since they are not office procedures and can only be performed in ASC/SPU or inpatient setting:
25111
26160
31535
43260
58120The following pulse oximetry procedure code will have the technical component (TC) and the professional component (26) pricing modifiers end-dated as this code represents only the technical component of the procedure consistent with the Current Procedural Terminology, 2009 Standard Edition, code book:
94761
The pricing modifiers (SG) and (26) are being added to the following surgical and diagnostic services currently designated as inpatient services, but which can safely be performed in an SPU or ASC, or both, depending on the procedure:
11983 (SG)
64475 (SG)
93640 (SG)
93641 (SG)
93640 (26)
93641 (26)Fee Changes
The Pennsylvania Medicaid State Plan (State Plan) specifies that maximum fees for services covered under the MA Program are to be determined on the basis of the following: fees may not exceed the Medicare upper limit when applicable; fees must be consistent with efficiency, economy and quality of care; and fees must be sufficient to assure the availability of services to recipients. The regulations at 55 Pa. Code § 1150.62(a) (relating to payment levels and notice of rate setting changes) also specify that the MA fees may not exceed the Medicare upper limit. Effective for dates of service on and after March 1, 2010, the following procedure codes will have the fee related to the SU modifier decreased to comply with these requirements:
Procedure Code Description Current MA Fee
(with SU modifier)MA Fee Effective
March 1, 2010
(with SU modifier)20220 Biopsy, bone, trocar, or needle; superficial (for example, ilium, sternum, spinous process, ribs) $683.80 $155.01 38500 Biopsy or excision of lymph nodes; open, superficial $638.80 $279.49 46230 Excision of external hemorrhoid tags and/or multiple papillae $660.80 $218.20 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examinations $815.80 $419.73 68420 Incision, drainage of lacrimal sac (dacryocystotomy or dacryocystostomy) $694.30 $255.44 Effective for dates of service on and after March 1, 2010, the following diagnostic procedure code must be billed with modifier (26) with the associated fee of $327.25:
Procedure Code Description Current MA Fee
(with no modifier)MA Fee Effective
March 1, 2010
(with 26 modifier)93641 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator $574.79 $327.25
Fiscal Impact
It is anticipated that these revisions will result in minimal savings; therefore, there will be 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 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).
HARRIET DICHTER,
Acting SecretaryFiscal Note: 14-NOT-634. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 10-296. Filed for public inspection February 12, 2010, 9:00 a.m.]
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