NOTICES
Medical Assistance Program Fee Schedule Revisions; 2014 Healthcare Common Procedure Coding System Updates; Prior Authorization Requirements
[44 Pa.B. 3642]
[Saturday, June 14, 2014]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 June 23, 2014.
Fee Schedule Revisions
The Department is adding and end-dating procedure codes as a result of implementing the 2014 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 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 an MA 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 2014 HCPCS updates:
Procedure Codes and Modifiers
10030 19081 19081 (SG) 19082 19083 19083 (SG) 19084 19085 19085 (SG) 19086 19281 19282 19283 19284 19285 19286 19287 19288 23333 (SG) 23333 (RT) 23333 (LT) 23333 (50) 23334 (SG) 23334 (RT) 23334 (LT) 23334 (50) 23334 (80) (RT) 23334 (80) (LT) 23334 (80) (50) 23335 (RT) 23335 (LT) 23335 (50) 23335 (80) (RT) 23335 (80) (LT) 23335 (80) (50) 37217(RT) 37217 (LT) 37217 (50) 37236 37236 (SG) 37237 37238 37238 (SG) 37239 37241 37241 (SG) 37242 37242 (SG) 37243 37243 (SG) 37244 37244 (SG) 43191 43191 (SG) 43192 43192 (SG) 43193 43193 (SG) 43194 43194 (SG) 43195 43195 (SG) 43196 43196 (SG) 43197 43197 (SG) 43198 43198 (SG) 43211 43211 (SG) 43212 43212 (SG) 43213 43213 (SG) 43214 43214 (SG) 43229 43229 (SG) 43233 43233 (SG) 43253 43253 (SG) 43254 43254 (SG) 43266 43266 (SG) 43270 43270 (SG) 43274 43274 (SG) 43275 43275 (SG) 43276 43276 (SG) 43277 43277 (SG) 43278 43278 (SG) 49405 49405 (SG) 49406 49406 (SG) 49407 49407 (SG) 52356 (SG) 52356 (RT) 52356 (LT) 52356 (50) 64616 (SG) 64616 (RT) 64616 (LT) 64616 (50) 64617 (SG) 64617 (RT) 64617 (LT) 64617(50) 64642 64642 (SG) 64643 64644 64644 (SG) 64645 64646 64646 (SG) 64647 64647 (SG) 77293 77293 (TC) 77293 (26) 80155 80159 80169 80171 80175 80177 80180 80183 80199 80203 81287 87661 90673 92521 (U9) 92522 (U9) 92523 (U9) 92524 (U9) 93582 93582 (SG) 93582 (80) 93583 93583 (80) A7047 (NU) G0461 G0461 (TC) G0461 (26) G0462 G0462 (TC) G0462 (26) L0455 L0457 L0467 L0469 L0641 L0642 L0643 L0648 L0649 L0650 L0651 L1812 (RT) L1812 (LT) L1812 (50) L1833 (RT) L1833 (LT) L1833 (50) L1848 (RT) L1848 (LT) L1848 (50) L3809 (RT) L3809 (LT) L3809 (50) L3916 (RT) L3916 (LT) L3916 (50) L3918 (RT) L3918 (LT) L3918 (50) L3924 (LT) L3924 (RT) L3924 (50) L3930 (RT) L3930 (LT) L3930 (50) L4361 (RT) L4361 (LT) L4361 (50) L4387 (RT) L4387 (LT) L4387 (50) L4397 (RT) L4397 (LT) L4397 (50) T4544 The following procedure codes are being added to the MA Program Fee Schedule based upon provider requests, clinical review or significant program exception requests:
Procedure Codes
81161 81200 81201 81202 81203 81211 81212 81213 81214 81215 81216 81217 81220 81240 81241 81243 81244 81245 81280 81281 81282 81292 81293 81294 81295 81296 81297 81298 81299 81300 81301 81302 81303 81304 81315 81316 81317 81318 81319 81324 81325 81326 81330 81331 81370 81371 81372 81373 81374 81375 81376 81377 81378 81379 81380 81381 81382 81383 81511 E0191 Q4107 The following procedure codes are being end-dated from the MA Program Fee Schedule either as a result of the 2014 HCPCS updates or because they were previously end-dated by CMS:
Procedure Codes
13150 19102 19103 19290 19291 19295 23331 23332 37204 37205 37206 37207 37208 37210 42802 43219 43228 43256 43258 43267 43268 43269 43271 43272 43456 43458 49021 49041 49061 64613 64614 75960 77031 77032 92506 93607 A4260 J1055 J7347 J7349 L7611 L7612 L7613 L7614 L7621 L7622 S3626 The Department is end-dating procedure code 88342 and replacing it with G0461 as a result of the 2014 HCPCS updates:
Procedure Code Description Replacement
Procedure
Code
Description 88342 Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide G0461
Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain In addition, the Department is end-dating the following procedure code from the MA Program Fee Schedule because it is considered a cosmetic surgical procedure. Under 55 Pa. Code § 1141.59(13) (relating to noncompensable services) payments will not be made for cosmetic surgery except when performed to improve the functioning of a malformed body member, to correct a visible disfigurement which would affect the ability of the person to obtain or hold employment, or as a post-mastectomy breast reconstruction.
Procedure Code Procedure Description 65765 Keratophakia No new authorizations will be issued for the procedure codes being end-dated on and after June 23, 2014. For any of the previous procedure codes that had a prior authorization issued before June 23, 2014, providers should submit claims using the end-dated procedure code, as set forth in the authorization issued by the Department. The Department will accept claims with the end-dated procedure codes until June 23, 2015, for those services that were previously prior authorized.
Prior Authorization Requirements
The following procedure codes for molecular pathology are being added to the MA Program Fee Schedule and will require prior authorization, as authorized under section 443.6(b)(7) of the Public Welfare Code (code) (62 P. S. § 443.6(b)(7)), and as described in the MA Provider Handbook which may be viewed at http://www.dpw.state.pa.us/publications/forproviders/promiseproviderhandbooksandbillingguides/index.htm.
Procedure Codes
81161 81200 81201 81202 81203 81211 81212 81213 81214 81215 81216 81217 81220 81240 81241 81243 81244 81245 81255 81256 81257 81260 81270 81275 81280 81281 81282 81287 81292 81293 81294 81295 81296 81297 81298 81299 81300 81301 81302 81303 81304 81315 81316 81317 81318 81319 81324 81325 81326 81330 81331 81370 81371 81372 81373 81374 81375 81376 81377 81378 81379 81380 81381 81382 81383 81511 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:
Procedure Code Procedure Description Q4107 Graft jacket, per square centimeter The following procedure codes being added to the MA Program Fee Schedule are orthoses and will require prior authorization, as authorized under section 443.6(b)(1) of the code:
Procedure Codes
L0455 L0457 L0467 L0469 L0641 L0642 L0643 L0648 L0649 L0650 L0651 L1812 (RT) L1812 (LT) L1812 (50) L1833 (RT) L1833 (LT) L1833 (50) L1848 (RT) L1848 (LT) L1848 (50) L3809 (RT) L3809 (LT) L3809 (50) L3916 (RT) L3916 (LT) L3916 (50) L3918 (RT) L3918 (LT) L3918 (50) L3924 (LT) L3924 (RT) L3924 (50) L3930 (RT) L3930 (LT) L3930 (50) L4361 (RT) L4361 (LT) L4361 (50) L4387 (RT) L4387 (LT) L4387 (50) L4397 (RT) L4397 (LT) L4397 (50) Updates to Procedure Codes Currently on the MA Program Fee Schedule
Right/Left/50 Modifiers
The surgical procedure code 69210 will have modifiers right (Rt), left (Lt) and bilateral (50) added because the description of the service changed as a result of the 2014 HCPCS updates. The procedures may be performed laterally or bilaterally. The units will be increased from 1 unit per day to 1-2 units because of the allowance of bilateral services.
The surgical procedure codes 31295, 31296, 31297 and 69210 will be updated to include Provider Type (PT), Provider Specialty (PS) and/or Place of Service (POS), as indicated as follows, in addition to what is presently indicated on the fee schedule:
Procedure Codes Provider Type/Specialty
(PT/PS)Place of Service (POS) 31295 31296 31/All 11—Office 31297 31295 31296 01/183 22—Outpatient Hospital 31297 31295 31296 08/082 49—Independent Clinic 31297 69210 01/183 22—Outpatient Hospital 69210 08/082 49—Independent Clinic Fiscal Impact
The estimated cost for Fiscal Year (FY) 2014-2015 is $0.301 million ($0.144 million in State funds). The estimated cost for FY 2015-2016 is $0.361 million ($0.174 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).
BEVERLY D. MACKERETH,
SecretaryFiscal Note: 14-NOT-880. (1) General Fund; (2) Implementing Year 2013-14 is $0; (3) 1st Succeeding Year 2014-15 is $144,000; 2nd Succeeding Year 2015-16 is $174,000; 3rd Succeeding Year 2016-17 is $174,000; 4th Succeeding Year 2017-18 is $174,000; 5th Succeeding Year 2018-19 is $174,000; (4) 2012-13 Program—$450,835,000; 2011-12 Program—$645,095,000; 2010-11 Program—$467,929,000; (7) MA—Outpatient; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 14-1282. Filed for public inspection June 13, 2014, 9:00 a.m.]
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