Pennsylvania Bulletin

PA Bulletin, Doc. No. 11-910

NOTICES

Medical Assistance Program Fee Schedule Revisions

[41 Pa.B. 2770]
[Saturday, May 28, 2011]

The Department of Public Welfare (Department) announces that it will revise the fees, or a component of the fee, on the Medical Assistance (MA) Program Fee Schedule for select medical, surgical, laboratory, durable medical equipment and radiological services effective May 30, 2011.

Fee Schedule Revisions

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. MA regulations in 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.

The Department has determined that MA fees for approximately 112 medical, surgical, laboratory, durable medical equipment and radiological procedure codes or combinations of procedure codes and modifiers are above the Medicare upper limit for the same procedure codes. The Department is adjusting the fees on the MA Program Fee Schedule for these combinations of procedure codes and modifiers to equal the Medicare upper limit. Revision of these fees is necessary to comply with the regulation and State Plan and to avoid a Federal disallowance.

As set forth as follows, the Department has revised the total fee (billed with no modifier) and, as applicable, the professional component fee (billed with modifier 26), the technical component fee (billed with modifier TC), the physician office procedure fee (billed with modifier SU) and the fee when billing for the purchase (billed with modifier NU) or rental (billed with modifier RR) of durable medical equipment. ''N/A'' indicates that the modifier is not on the MA Program Fee Schedule for the procedure code and ''N/C'' indicates that there is no change in the fee associated with the modifier:

Procedure
Code Procedure Code Description Professional Component
Fee Revision (Billing with Modifier 26) Technical Component
Fee Revision (Billing with Modifier TC) Billing with
No Modifier
or with
Pricing
Modifier SU Billing with Pricing
Modifiers
NU or RR

25335 Centralization of wrist on ulna (for example, radial club hand) N/A N/A $815.98 N/A

27250 Closed treatment of hip dislocation, traumatic; without anesthesia N/A N/A $204.65 N/A

52400 Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive hypertrophic mucosal folds N/A N/A $493.01 N/A

52640 Transurethral resection; of postoperative bladder neck contracture N/A N/A $303.27 N/A

55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) N/A N/A $417.84 (SU) N/A

55873 Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) N/A N/A $855.70 N/A

57155 Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy N/A N/A $179.75 N/A

59414 Delivery of placenta (separate procedure) N/A N/A $85.42 N/A

59857 Induced abortion, by 1 or more vaginal suppositories (for example, prostaglandin) with or without cervical dilation (for example, laminaria), including hospital admission and visits, delivery of fetus and secundines; with hysterotomy (failed medical evacuation) N/A N/A $516.11 N/A

64416 Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement) N/A N/A $81.06 N/A

64446 Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement) N/A N/A $82.36 N/A

64448 Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement) N/A N/A $73.22 N/A

64449 Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) N/A N/A $83.66 N/A

67028 Intravitreal injection of a pharmacologic agent (separate procedure) N/A N/A $105.88 N/A

69801 Labyrinthotomy, with perfusion of vestibuloactive drug(s); transcanal N/A N/A $294.59 N/A

70371 Complex dynamic pharyngeal and speech evaluation by cine or video recording $40.73 $48.42 N/C N/A

71250 Computed tomography, thorax; without contrast material $50.49 $83.10 N/C N/A

72125 Computed tomography, cervical spine; without contrast material $50.49 $83.10 N/C N/A

72128 Computed tomography, thoracic spine; without contrast material $50.49 $90.60 N/C N/A

72131 Computed tomography, lumbar spine; without contrast material $50.49 $88.10 N/C N/A

73020 Radiologic examination, shoulder; 1 view $7.42 $14.51 N/C N/A

73200 Computed tomography, upper extremity; without contrast material $50.59 $79.04 N/C N/A

73700 Computed tomography, lower extremity; without contrast material $50.59 $79.04 N/C N/A

74485 Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation $26.96 $77.77 N/C N/A

75630 Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation $89.30 $154.98 $244.28 N/A

75962 Transluminal balloon angioplasty, peripheral artery other than cervical carotid, renal or other visceral artery, iliac or lower extremity, radiological supervision and interpretation $26.63 $178.42 $205.05 N/A

75964 Transluminal balloon angioplasty, each additional peripheral artery other than cervical carotid, renal or other visceral artery, iliac and lower extremity, radiological supervision and interpretation (List separately in addition to code for primary procedure) $18.28 $109.74 $128.02 N/A

75966 Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation $66.01 $181.67 $247.68 N/A

75968 Transluminal balloon angioplasty, each additional visceral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure) $17.81 $107.46 $125.27 N/A

75978 Transluminal balloon angioplasty, venous (for example, subclavian stenosis), radiological supervision and interpretation $26.30 $179.07 $205.37 N/A

76098 Radiological examination, surgical specimen $8.09 $10.62 N/C N/A

76820 Doppler velocimetry, fetal; umbilical artery $24.20 $21.53 $45.73 N/A

76827 Doppler echocardio-
graphy, fetal, pulsed wave and/or continuous wave with spectral display; complete $27.89 $36.55 N/C N/A

76946 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation $18.49 $18.60 $37.09 N/A

76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method $2.72 $7.53 $10.25 N/A

77012 Computed tomography guidance for needle placement (for example, biopsy, aspiration, injection, localization device), radiological supervision and interpretation $56.53 $102.25 $158.78 N/A

77031 Stereotactic localization guidance for breast biopsy or needle placement (for example, for wire localization or for injection), each lesion, radiological supervision and interpretation $79.67 $78.17 $157.84 N/A

77051 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure) $3.06 $8.19 $11.25 N/A

77052 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure) $3.06 $8.19 $11.25 N/A

77053 Mammary ductogram or galactogram, single duct, radiological supervision and interpretation $17.49 $48.22 $65.71 N/A

77079 Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (for example, radius, wrist, heel) $10.78 $38.46 $49.24 N/A

77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (for example, radius, wrist, heel) $9.80 $17.68 N/C N/A

77295 Therapeutic radiology simulation-aided field setting; 3-dimensional $227.38 $321.46 $548.84 N/A

77305 Teletherapy, isodose plan (whether hand or computer calculated); simple (1 or 2 parallel opposed unmodified ports directed to a single area of interest) $21.18 $30.32 N/C N/A

77333 Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus) $41.75 $16.97 $58.72 N/A

77620 Hyperthermia generated by intracavitary probe(s) $74.68 $110.15 N/C N/A

78016 Thyroid carcinoma metastases imaging; with additional studies (for example, urinary recovery) $37.45 $56.55 N/C N/A

78320 Bone and/or joint imaging; tomographic (SPECT) $50.55 $176.58 N/C N/A

78710 Kidney imaging morphology; tomographic (SPECT) $30.94 $175.06 N/C N/A

78730 Urinary bladder residual study (List separately in addition to code for primary procedure) $8.07 $36.15 N/C N/A

79403 Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion $110.83 $88.35 $199.18 N/A

80047 Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330), Carbon dioxide (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Potassium (84132), Sodium (84295), Urea Nitrogen (BUN) (84520) N/A N/A $11.91 N/A

88182 Flow cytometry, cell cycle or DNA analysis $34.44 $6.87 N/C N/A

88355 Morphometric analysis; skeletal muscle $82.95 $33.32 N/C N/A

88358 Morphometric analysis; tumor (for example, DNA ploidy) $41.86 $20.63 N/C N/A

89230 Sweat collection by iontophoresis N/A N/A $2.98 N/A

91040 Esophageal balloon distension provocation study $49.38 $280.62 $330.00 N/A

92285 External ocular photography with interpretation and report for documentation of medical progress (for example, close-up photography, slit lamp photography, goniophotography, stereo-photography) $4.03 $9.22 N/C N/A

92977 Thrombolysis, coronary; by intravenous infusion N/A N/A $88.68 N/A

93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report N/A N/A $19.22 N/A

93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report N/A N/A $10.46 N/A

93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report N/A N/A $89.75 N/A

93224 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation N/A N/A $93.65 N/A

93226 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report N/A N/A $39.76 N/A

93270 External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; recording (includes connection, recording, and disconnection) N/A N/A $14.70 N/A

93278 Signal-averaged electrocardiography (SAECG), with or without ECG $12.45 $21.53 $33.98 N/A

93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete $19.14 $41.39 $60.53 N/A

93321 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study (List separately in addition to codes for echocardiographic imaging) $7.75 $20.55 $28.30 N/A

93724 Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings) $251.30 $44.32 $295.62 N/A

95811 Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist $129.89 $517.67 N/C N/A

96151 Health and behavior assessment (for example, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment N/A N/A $19.94 N/A

96154 Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present) N/A N/A $18.59 N/A

97598 Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (for example, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) N/A N/A $11.56 N/A

E0143 Walker, folding, wheeled, adjustable or fixed height N/A N/A N/A N/C (NU)
$19.52 (RR)

E0158 Leg extensions for walker, per set of 4 N/A N/A N/A $29.09 (NU)

E0250 Hospital bed, fixed height, with any type side rails, with mattress N/A N/A N/A N/C (NU)
$88.38 (RR)

E0251 Hospital bed, fixed height, with any type side rails, without mattress N/A N/A N/A N/C (NU)
$66.97 (RR)

E0255 Hospital bed, variable height, hi-lo, with any type side rails, with mattress N/A N/A N/A N/C (NU) $103.40 (RR)

E0256 Hospital bed, variable height, hi-lo, with any type side rails, without mattress N/A N/A N/A N/C (NU)
$70.60 (RR)

E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress N/A N/A N/A N/C (NU) $126.99 (RR)

E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress N/A N/A N/A N/C (NU) $116.31 (RR)

E0271 Mattress, innerspring N/A N/A N/A N/C (NU)
$20.85 (RR)

E0272 Mattress, foam rubber N/A N/A N/A N/C (NU)
$19.10 (RR)

E0280 Bed cradle, any type N/A N/A N/A $33.46 (NU)

E0290 Hospital bed, fixed height, without side rails, with mattress N/A N/A N/A N/C (NU)
$67.57 (RR)

E0291 Hospital bed, fixed height, without side rails, without mattress N/A N/A N/A N/C (NU)
$49.09 (RR)

E0292 Hospital bed, variable height, hi-lo, without side rails, with mattress N/A N/A N/A N/C (NU)
$73.30 (RR)

E0293 Hospital bed, variable height, hi-lo, without side rails, without mattress N/A N/A N/A N/C (NU)
$64.66 (RR)

E0296 Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress N/A N/A N/A N/C (NU) $148.45 (RR)

E0297 Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress N/A N/A N/A N/C (NU) $127.18 (RR)

E0431 Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing N/A N/A N/A $28.74 (RR)

E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing N/A N/A N/A $28.74 (RR)

E0560 Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery N/A N/A N/A $18.17 (RR)

E0910 Trapeze bars, also known as Patient Helper, attached to bed, with grab bar N/A N/A N/A N/C (NU)
$18.08 (RR)

E2209 Accessory, arm trough, with or without hand support, each N/A N/A N/A $96.88 (NU) $9.71 (RR)

E2210 Wheelchair accessory, bearings, any type, replacement only, each N/A N/A N/A $5.92 (NU)

E2601 General use wheelchair seat cushion, width less than 22 in, any depth N/A N/A N/A $55.29 (NU) $5.54 (RR)

E2602 General use wheelchair seat cushion, width 22 in or greater, any depth N/A N/A N/A $107.95 (NU) $10.80 (RR)

E2603 Skin protection wheelchair seat cushion, width less than 22 in, any depth N/A N/A N/A $137.05 (NU) $13.72 (RR)

E2604 Skin protection wheelchair seat cushion, width 22 in or greater, any depth N/A N/A N/A $170.34 (NU) $17.02 (RR)

E2605 Positioning wheelchair seat cushion, width less than 22 in, any depth N/A N/A N/A $243.36 (NU) $24.35 (RR)

E2611 General use wheelchair back cushion, width less than 22 in, any height, including any type mounting hardware N/A N/A N/A $282.40 (NU) $28.23 (RR)

E2612 General use wheelchair back cushion, width 22 in or greater, any height, including any type mounting hardware N/A N/A N/A $382.02 (NU) $38.20 (RR)

Q0035 Cardiokymography $8.10 $9.82 $17.92 N/A

Fiscal Impact

It is anticipated that these revisions will result in savings of $0.135 million ($0.065 million in State funds) in the MA Outpatient Program in Fiscal Year 2011-2012 and annualized savings of $0.147 million ($0.071 million in State funds) in Fiscal Year 2012-2013. These State fund estimates are based on the increased Federal Medical Assistance Percentages as determined under the American Recovery and Reinvestment Act of 2009.

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 revisions of the MA Program Fee Schedule.

Persons with a disability who require auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).

GARY D. ALEXANDER,
Acting Secretary

Fiscal Note: 14-NOT-694. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 11-910. Filed for public inspection May 27, 2011, 9:00 a.m.]

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Procedure Code	Procedure Code Description	Professional Component Fee Revision (Billing with Modifier 26)	Technical Component Fee Revision (Billing with Modifier TC)	Billing with No Modifier or with Pricing Modifier SU	Billing with Pricing Modifiers NU or RR
25335	Centralization of wrist on ulna (for example, radial club hand)	N/A	N/A	$815.98	N/A
27250	Closed treatment of hip dislocation, traumatic; without anesthesia	N/A	N/A	$204.65	N/A
52400	Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive hypertrophic mucosal folds	N/A	N/A	$493.01	N/A
52640	Transurethral resection; of postoperative bladder neck contracture	N/A	N/A	$303.27	N/A
55250	Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)	N/A	N/A	$417.84 (SU)	N/A
55873	Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring)	N/A	N/A	$855.70	N/A
57155	Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy	N/A	N/A	$179.75	N/A
59414	Delivery of placenta (separate procedure)	N/A	N/A	$85.42	N/A
59857	Induced abortion, by 1 or more vaginal suppositories (for example, prostaglandin) with or without cervical dilation (for example, laminaria), including hospital admission and visits, delivery of fetus and secundines; with hysterotomy (failed medical evacuation)	N/A	N/A	$516.11	N/A
64416	Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement)	N/A	N/A	$81.06	N/A
64446	Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement)	N/A	N/A	$82.36	N/A
64448	Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement)	N/A	N/A	$73.22	N/A
64449	Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement)	N/A	N/A	$83.66	N/A
67028	Intravitreal injection of a pharmacologic agent (separate procedure)	N/A	N/A	$105.88	N/A
69801	Labyrinthotomy, with perfusion of vestibuloactive drug(s); transcanal	N/A	N/A	$294.59	N/A
70371	Complex dynamic pharyngeal and speech evaluation by cine or video recording	$40.73	$48.42	N/C	N/A
71250	Computed tomography, thorax; without contrast material	$50.49	$83.10	N/C	N/A
72125	Computed tomography, cervical spine; without contrast material	$50.49	$83.10	N/C	N/A
72128	Computed tomography, thoracic spine; without contrast material	$50.49	$90.60	N/C	N/A
72131	Computed tomography, lumbar spine; without contrast material	$50.49	$88.10	N/C	N/A
73020	Radiologic examination, shoulder; 1 view	$7.42	$14.51	N/C	N/A
73200	Computed tomography, upper extremity; without contrast material	$50.59	$79.04	N/C	N/A
73700	Computed tomography, lower extremity; without contrast material	$50.59	$79.04	N/C	N/A
74485	Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation	$26.96	$77.77	N/C	N/A
75630	Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation	$89.30	$154.98	$244.28	N/A
75962	Transluminal balloon angioplasty, peripheral artery other than cervical carotid, renal or other visceral artery, iliac or lower extremity, radiological supervision and interpretation	$26.63	$178.42	$205.05	N/A
75964	Transluminal balloon angioplasty, each additional peripheral artery other than cervical carotid, renal or other visceral artery, iliac and lower extremity, radiological supervision and interpretation (List separately in addition to code for primary procedure)	$18.28	$109.74	$128.02	N/A
75966	Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation	$66.01	$181.67	$247.68	N/A
75968	Transluminal balloon angioplasty, each additional visceral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure)	$17.81	$107.46	$125.27	N/A
75978	Transluminal balloon angioplasty, venous (for example, subclavian stenosis), radiological supervision and interpretation	$26.30	$179.07	$205.37	N/A
76098	Radiological examination, surgical specimen	$8.09	$10.62	N/C	N/A
76820	Doppler velocimetry, fetal; umbilical artery	$24.20	$21.53	$45.73	N/A
76827	Doppler echocardio- graphy, fetal, pulsed wave and/or continuous wave with spectral display; complete	$27.89	$36.55	N/C	N/A
76946	Ultrasonic guidance for amniocentesis, imaging supervision and interpretation	$18.49	$18.60	$37.09	N/A
76977	Ultrasound bone density measurement and interpretation, peripheral site(s), any method	$2.72	$7.53	$10.25	N/A
77012	Computed tomography guidance for needle placement (for example, biopsy, aspiration, injection, localization device), radiological supervision and interpretation	$56.53	$102.25	$158.78	N/A
77031	Stereotactic localization guidance for breast biopsy or needle placement (for example, for wire localization or for injection), each lesion, radiological supervision and interpretation	$79.67	$78.17	$157.84	N/A
77051	Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure)	$3.06	$8.19	$11.25	N/A
77052	Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure)	$3.06	$8.19	$11.25	N/A
77053	Mammary ductogram or galactogram, single duct, radiological supervision and interpretation	$17.49	$48.22	$65.71	N/A
77079	Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (for example, radius, wrist, heel)	$10.78	$38.46	$49.24	N/A
77081	Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (for example, radius, wrist, heel)	$9.80	$17.68	N/C	N/A
77295	Therapeutic radiology simulation-aided field setting; 3-dimensional	$227.38	$321.46	$548.84	N/A
77305	Teletherapy, isodose plan (whether hand or computer calculated); simple (1 or 2 parallel opposed unmodified ports directed to a single area of interest)	$21.18	$30.32	N/C	N/A
77333	Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus)	$41.75	$16.97	$58.72	N/A
77620	Hyperthermia generated by intracavitary probe(s)	$74.68	$110.15	N/C	N/A
78016	Thyroid carcinoma metastases imaging; with additional studies (for example, urinary recovery)	$37.45	$56.55	N/C	N/A
78320	Bone and/or joint imaging; tomographic (SPECT)	$50.55	$176.58	N/C	N/A
78710	Kidney imaging morphology; tomographic (SPECT)	$30.94	$175.06	N/C	N/A
78730	Urinary bladder residual study (List separately in addition to code for primary procedure)	$8.07	$36.15	N/C	N/A
79403	Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion	$110.83	$88.35	$199.18	N/A
80047	Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330), Carbon dioxide (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Potassium (84132), Sodium (84295), Urea Nitrogen (BUN) (84520)	N/A	N/A	$11.91	N/A
88182	Flow cytometry, cell cycle or DNA analysis	$34.44	$6.87	N/C	N/A
88355	Morphometric analysis; skeletal muscle	$82.95	$33.32	N/C	N/A
88358	Morphometric analysis; tumor (for example, DNA ploidy)	$41.86	$20.63	N/C	N/A
89230	Sweat collection by iontophoresis	N/A	N/A	$2.98	N/A
91040	Esophageal balloon distension provocation study	$49.38	$280.62	$330.00	N/A
92285	External ocular photography with interpretation and report for documentation of medical progress (for example, close-up photography, slit lamp photography, goniophotography, stereo-photography)	$4.03	$9.22	N/C	N/A
92977	Thrombolysis, coronary; by intravenous infusion	N/A	N/A	$88.68	N/A
93000	Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report	N/A	N/A	$19.22	N/A
93005	Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report	N/A	N/A	$10.46	N/A
93015	Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report	N/A	N/A	$89.75	N/A
93224	External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation	N/A	N/A	$93.65	N/A
93226	External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report	N/A	N/A	$39.76	N/A
93270	External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; recording (includes connection, recording, and disconnection)	N/A	N/A	$14.70	N/A
93278	Signal-averaged electrocardiography (SAECG), with or without ECG	$12.45	$21.53	$33.98	N/A
93320	Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete	$19.14	$41.39	$60.53	N/A
93321	Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study (List separately in addition to codes for echocardiographic imaging)	$7.75	$20.55	$28.30	N/A
93724	Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings)	$251.30	$44.32	$295.62	N/A
95811	Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist	$129.89	$517.67	N/C	N/A
96151	Health and behavior assessment (for example, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment	N/A	N/A	$19.94	N/A
96154	Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)	N/A	N/A	$18.59	N/A
97598	Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (for example, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)	N/A	N/A	$11.56	N/A
E0143	Walker, folding, wheeled, adjustable or fixed height	N/A	N/A	N/A	N/C (NU) $19.52 (RR)
E0158	Leg extensions for walker, per set of 4	N/A	N/A	N/A	$29.09 (NU)
E0250	Hospital bed, fixed height, with any type side rails, with mattress	N/A	N/A	N/A	N/C (NU) $88.38 (RR)
E0251	Hospital bed, fixed height, with any type side rails, without mattress	N/A	N/A	N/A	N/C (NU) $66.97 (RR)
E0255	Hospital bed, variable height, hi-lo, with any type side rails, with mattress	N/A	N/A	N/A	N/C (NU) $103.40 (RR)
E0256	Hospital bed, variable height, hi-lo, with any type side rails, without mattress	N/A	N/A	N/A	N/C (NU) $70.60 (RR)
E0260	Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress	N/A	N/A	N/A	N/C (NU) $126.99 (RR)
E0261	Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress	N/A	N/A	N/A	N/C (NU) $116.31 (RR)
E0271	Mattress, innerspring	N/A	N/A	N/A	N/C (NU) $20.85 (RR)
E0272	Mattress, foam rubber	N/A	N/A	N/A	N/C (NU) $19.10 (RR)
E0280	Bed cradle, any type	N/A	N/A	N/A	$33.46 (NU)
E0290	Hospital bed, fixed height, without side rails, with mattress	N/A	N/A	N/A	N/C (NU) $67.57 (RR)
E0291	Hospital bed, fixed height, without side rails, without mattress	N/A	N/A	N/A	N/C (NU) $49.09 (RR)
E0292	Hospital bed, variable height, hi-lo, without side rails, with mattress	N/A	N/A	N/A	N/C (NU) $73.30 (RR)
E0293	Hospital bed, variable height, hi-lo, without side rails, without mattress	N/A	N/A	N/A	N/C (NU) $64.66 (RR)
E0296	Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress	N/A	N/A	N/A	N/C (NU) $148.45 (RR)
E0297	Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress	N/A	N/A	N/A	N/C (NU) $127.18 (RR)
E0431	Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing	N/A	N/A	N/A	$28.74 (RR)
E0434	Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing	N/A	N/A	N/A	$28.74 (RR)
E0560	Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery	N/A	N/A	N/A	$18.17 (RR)
E0910	Trapeze bars, also known as Patient Helper, attached to bed, with grab bar	N/A	N/A	N/A	N/C (NU) $18.08 (RR)
E2209	Accessory, arm trough, with or without hand support, each	N/A	N/A	N/A	$96.88 (NU) $9.71 (RR)
E2210	Wheelchair accessory, bearings, any type, replacement only, each	N/A	N/A	N/A	$5.92 (NU)
E2601	General use wheelchair seat cushion, width less than 22 in, any depth	N/A	N/A	N/A	$55.29 (NU) $5.54 (RR)
E2602	General use wheelchair seat cushion, width 22 in or greater, any depth	N/A	N/A	N/A	$107.95 (NU) $10.80 (RR)
E2603	Skin protection wheelchair seat cushion, width less than 22 in, any depth	N/A	N/A	N/A	$137.05 (NU) $13.72 (RR)
E2604	Skin protection wheelchair seat cushion, width 22 in or greater, any depth	N/A	N/A	N/A	$170.34 (NU) $17.02 (RR)
E2605	Positioning wheelchair seat cushion, width less than 22 in, any depth	N/A	N/A	N/A	$243.36 (NU) $24.35 (RR)
E2611	General use wheelchair back cushion, width less than 22 in, any height, including any type mounting hardware	N/A	N/A	N/A	$282.40 (NU) $28.23 (RR)
E2612	General use wheelchair back cushion, width 22 in or greater, any height, including any type mounting hardware	N/A	N/A	N/A	$382.02 (NU) $38.20 (RR)
Q0035	Cardiokymography	$8.10	$9.82	$17.92	N/A

NOTICES

Medical Assistance Program Fee Schedule Revisions

[41 Pa.B. 2770][Saturday, May 28, 2011]

[Pa.B. Doc. No. 11-910. Filed for public inspection May 27, 2011, 9:00 a.m.]

[41 Pa.B. 2770]
[Saturday, May 28, 2011]