NOTICES
DEPARTMENT OF PUBLIC WELFARE
Medical Assistance Program Fee Schedule Revisions; 2011 HCPCS Updates; Prior Authorization Requirements
[41 Pa.B. 4259]
[Saturday, August 6, 2011]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 August 8, 2011.
Fee Schedule Revisions
The Department is adding and end-dating procedure codes as a result of implementing the 2011 updates made by the Centers for Medicare and Medicaid Services (CMS) to the Healthcare Common Procedure Coding System (HCPCS). The Department is also adding and end-dating other procedure codes. 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 will be published in a Medical Assistance Bulletin that will be issued to all providers.
The following procedure codes, or procedure code and modifier combinations, are being added to the MA Program Fee Schedule as a result of the 2011 HCPCS updates:
Procedure Codes and Modifiers
11045 11046 11047 22551 22551 (80) 22552 22552 (80) 29914 29914 (SG) 29915 29915 (SG) 29916 29916 (SG) 31295 31295 (SG) 31296 31296 (SG) 31297 31297 (SG) 31634 31634 (SG) 33620 33620 (80) 33621 33621 (80) 33622 33622 (80) 37220 37220 (80) 37220 (SG) 37221 37221 (80) 37221 (SG) 37222 37222 (80) 37223 37223 (80) 37224 37224 (80) 37224 (SG) 37225 37225 (80) 37225 (SG) 37226 37226 (80) 37226 (SG) 37227 37227 (80) 37227 (SG) 37228 37228 (80) 37228 (SG) 37229 37229 (80) 37229 (SG) 37230 37230 (80) 37230 (SG) 37231 37231 (80) 37231 (SG) 37232 37232 (80) 37233 37233 (80) 37234 37234 (80) 37235 37235 (80) 38900 43283 43283 (80) 43327 43327 (80) 43328 43328 (80) 43332 43332 (80) 43333 43333 (80) 43334 43334 (80) 43335 43335 (80) 43336 43336 (80) 43337 43337 (80) 43338 43338 (80) 43753 43753 (SG) 43754 43754 (SG) 43755 43755 (SG) 43756 43756 (SG) 43757 43757 (SG) 49327 49327 (80) 49412 49412 (80) 49418 49418 (SG) 57156 57156 (SG) 64568 64568 (SG) 64569 64569 (SG) 64570 64570 (SG) 64611 65778 65778 (SG) 65779 65779 (SG) 74176 74176 (TC) 74176 (26) 74177 74177 (TC) 74177 (26) 74178 74178 (TC) 74178 (26) 76881 76881(TC) 76881 (26) 76882 76882 (TC) 76882 (26) 80104 82930 85598 86481 86902 87501 87502 87503 87906 88120 88120 (TC) 88120 (26) 88121 88121(TC) 88121 (26) 88363 91013 91013 (TC) 91013 (26) 91117 92132 92132 (TC) 92132 (26) 92133 92133 (TC) 92133 (26) 92134 92134 (TC) 92134 (26) 92227 92228 92228 (TC) 92228 (26) 93451 (SG) 93451 (26) 93452 (SG) 93452 (26) 93453 (SG) 93453 (26) 93454 (SG) 93454 (26) 93455 (SG) 93455 (26) 93456 (SG) 93456 (26) 93457 (SG) 93457 (26) 93458 (SG) 93458 (26) 93459 (SG) 93459 (26) 93460 (SG) 93460 (26) 93461 (SG) 93461 (26) 93462 93464 (26) 93563 93564 93565 93566 93567 93568 96446 A4566 A7020 E2622 (NU) E2623 (NU) E2624 (NU) E2625 (NU) L3674 L4631 The following procedure codes are being added to the MA Program Fee Schedule as a result of significant program exception requests:
Procedure Codes and Modifiers
69220 V5170 V5180 V5190 V5200 V5210 V5220 V5230 V5240 The following 2010 HCPCS procedure codes are being added to the MA Program Fee Schedule. The Department has established pricing and is now adding the procedure codes to the MA Program Fee Schedule:
Procedure Code Procedure Description L2861 Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each L3891 Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each The following procedure codes are being end-dated from the MA Program Fee Schedule either as a result of the 2011 HCPCS updates or because they were previously end-dated by CMS:
Procedure Codes
11040 11041 20000 33861 35454 35456 35459 35470 35473 35474 35480 35481 35482 35483 35484 35485 35490 35491 35492 35493 35494 35495 39502 39520 39530 39531 43324 43326 43600 49420 64573 75992 75993 75994 75995 75996 76150 76880 82926 82928 86903 89105 89225 89235 91011 91012 91055 92135 93012 93014 93230 93231 93232 93233 93235 93236 93237 93501 93510 93511 93514 93524 93526 93527 93528 93529 93539 93540 93541 93542 93543 93544 93545 93555 93556 96445 K0734 K0735 K0736 K0737 L3672 L3673 The following procedure code is being end-dated from the MA Program Fee Schedule as a result of the 2011 HCPCS update which added the word ''unattended'' to the description. The MA Program does not cover unattended electroencephalographic (EEG) monitoring as it is not the accepted standard of practice.
Procedure Code Procedure Description 95953 Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, EEG recording and interpretation, each 24 hours, unattended. Prior Authorization Requirements
The Department is removing the prior authorization requirement for the following procedure code, which currently appears on the MA Program Fee Schedule, because it is not a prosthetic, but the dispensing of a prosthetic, and therefore does not 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) (Act 42):
Procedure Code Procedure Description V5160 Dispensing fee, binaural 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 code, as amended by Act 42:
Procedure Code Procedure Description L2861 Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each L3674 Shoulder orthosis, abduction positioning (airplane design), thoracic component L3891 Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each L4631 Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, V5170 Hearing aid, CROS, in the ear V5180 Hearing aid, CROS, behind the ear V5190 Hearing aid, CROS, glasses V5210 Hearing aid, BICROS, in the ear V5220 Hearing aid, BICROS, behind the ear V5230 Hearing aid, BICROS, glasses The following procedure code being added to the MA Program Fee Schedule will require prior authorization, as authorized under section 443.6(b)(7) of the code, as amended by Act 42:
Procedure Code Procedure Description A7020 Interface for cough stimulating device, includes all components, replacement The following procedure codes being added to the MA Program Fee Schedule are considered advanced radiology services and will require prior authorization as described in MA Bulletin 99-08-08 (Prior Authorization of Advanced Radiologic Imaging Services) which may be viewed online at http://services.dpw.state.pa.us/olddpw/bulletinsearch.aspx:
Procedure Code Procedure Description 74176 Computed tomography, abdomen and pelvis; without contrast material 74177 Computed tomography, abdomen and pelvis; with contrast material(s) 74178 Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions Fiscal Impact
The estimated cost for Fiscal Year (FY) 2011-2012 is $2.730 million ($1.255 million in State funds). The annualized cost for FY 2012-2013 is $3.275 million ($1.520 million in State funds).
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).
GARY D. ALEXANDER,
SecretaryFiscal Note: 14-NOT-710. (1) General Fund; (2) Implementing Year 2011-12 is $1,255,000; (3) 1st Succeeding Year 2012-13 is $1,520,000; 2nd Succeeding Year 2013-14 is $1,523,000; 3rd Succeeding Year 2014-15 is $1,523,000; 4th Succeeding Year 2015-16 is $1,523,000; 5th Succeeding Year 2016-17 is $1,523,000; (4) 2008-09 Program—$555,085,000; 2009-10 Program—$435,939,000; 2010-11 Program—$357,358,000; (7) MA—Outpatient; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 11-1327. Filed for public inspection August 5, 2011, 9:00 a.m.]
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