NOTICES
Medical Assistance Program Fee Schedule Revisions
[45 Pa.B. 1035]
[Saturday, February 28, 2015]The Department of Human Services (Department) announces changes to the Medical Assistance (MA) Program Fee Schedule. These changes are effective for dates of service on and after March 2, 2015.
Fee Schedule Revisions
The Department is updating the MA Program Fee Schedule in response to indicators specified by the Centers for Medicare and Medicaid Services (CMS), requests received from providers, and clinical reviews by Department staff related to standards of practice, provider type/specialty combinations (PT/Spec), place of service (POS) and procedure code/modifier combinations.
The Department is also revising fees for specified services or a component of the fee for select services in order that the fee does not exceed the Medicare Upper Limit.
Physician Services
Radiology procedure code 74420 is being added for PT/Spec 31 (Physician)/All with modifier 26 (professional component) in POS 24 (Ambulatory Surgical Center)/Short Procedure Unit) and 99 (Special Treatment Room).
The following radiology procedure codes will have POS 21 (Inpatient Hospital), 24 and/or 99 added for PT/Spec 31/341 (Radiologist) with modifier 26 as indicated:
Procedure
CodePOS Modifier Procedure
CodePOS Modifier 73525 24 26 74190 24 26 74235 24, 99 26 74300 24 26 74301 24 26 74305 24 26 74355 24 26 74360 24, 99 26 74363 24 26 74425 24 26 74450 21, 24 26 74470 21, 24 26 75801 24 26 75803 24 26 75805 24 26 75807 24 26 75894 24 26 75896 24 26 75970 24 26 75980 24 26 76932 24, 99 26 76975 24 26 The following radiology procedure codes will be end-dated for PT/Spec 31/All and re-opened for PT/Spec 31/341 in POS 21, 22 (Outpatient Hospital), 23 (Emergency Room) and/or 49 (Independent Clinic) with modifier 26 as indicated:
Procedure
CodePOS Modifier Procedure
CodePOS Modifier 74235 21, 22, 49 26 74300 21 26 74301 21 26 74305 21 26 74355 21 26 74360 21, 22, 49 26 74363 21, 22 26 74470 22 26 74775 21, 22 26 75801 21, 22 26 75803 21, 22 26 75805 21, 22 26 75807 21, 22 26 75810 21, 22 26 75952 21 26 75953 21 26 75956 21 26 75957 21 26 75958 21 26 75959 21 26 75970 21, 22 26 75980 21, 22 26 75982 21, 22 26 76120 21, 22, 23 26 76125 21, 22, 23 26 76932 21, 22 26 76975 21, 22 26 Laboratory procedure codes 88371 and 88372 will be end-dated for PT/Spec 31/All and re-opened for PT/Spec 31/333 (Pathologist).
Dental Services
Procedure code 70170 will have PT 27 (Dentist) end-dated because the procedure is outside the provider's scope of practice, beyond their scope of education or training, or both.
Emergency Room Services
Radiology procedures codes 74425 and 74450 will be end-dated for PT/Spec 01 (Inpatient Facility)/016 (ER Arrangement 1) in POS 23 because under this arrangement, payment would be made to the physician.
Laboratory Services
The following laboratory procedure codes will be end-dated for PT/Specs, indicated as follows, in POS 22, because the payment for these procedure codes is included in the hospital's per diem payment.
Procedure
CodePT/Spec POS 84703
86255
86701
01/012 (Med Rehab Hospital)
01/014 (Med Rehab Unit)
01/019 (D&A Hospital)
01/441 (D&A Rehab Hospital)22 86703 01/019 22 Laboratory procedure codes 81000, 85014 and 85018 will be end-dated for PT/Spec 01/015 (Children's Specialty Hospital) because the Department does not enroll providers under this specialty.
Modifier Updates
Right/Left/50 Modifiers
Procedure code 70170 will have the modifiers right (Rt), left (Lt) and bilateral (50) added because the procedure may be performed bilaterally.
Procedure codes 77053 and 77054 will have modifiers Rt, Lt, and 50 end-dated because the procedure code description specifies a single side or bilateral service.
TC/26/Total Modifiers
The following radiology procedure codes will only be paid when submitted with the professional component modifier (26):
Procedure Code 26 Modifier Pricing Procedure Code 26 Modifier Pricing 75956 $320.46 75957 $264.85 75958 $176.38 75959 $154.98 Laboratory procedure codes 88360 and 88361 will have the technical component (TC) modifier end-dated for PT/Spec 28/280 in POS 81 (Independent Laboratory) because only the total component may be billed.
The following laboratory procedure codes will have PT/PS 31/333 (Pathologist) added with the modifiers 26 and family planning (FP) in POS, as indicated, with applicable pricing:
Procedure Code Modifier 26 Modifier Pricing POS 83020 26 $15.21 21, 22, 23 84165 26 $15.21 21, 22, 23 84166 26 $15.21 21, 22, 23 84181 26 $15.21 21, 22, 23 84182 26 $15.21 21, 22, 23 85390 26 $15.21 21, 22, 23 85576 26 $15.21 21, 22 86255 26 $15.21 21, 22, 23 86255 26, FP $15.21 22, 49 86256 26 $14.60 21, 22, 23 86320 26 $14.60 21, 22, 23 86325 26 $14.60 21, 22, 23 86327 26 $17.17 21, 22, 23 86334 26 $15.21 21, 22, 23 86335 26 $15.21 21, 22, 23 87164 26 $15.21 21, 22, 23 87207 26 $15.21 21, 22, 23 87207 26, FP $15.21 22, 49 88161 26 $7.20 21, 22, 23 88161 26, FP $7.20 22, 49 88311 26 $10.53 21, 22, 23 88371 26 $15.21 21, 22, 23 88372 26 $15.21 21, 22, 23 89060 26 $15.21 21, 22, 23 The following laboratory procedure codes will have the TC and FP modifiers added to PT/Spec, as indicated, with applicable pricing:
Procedure Code PT/Specialty Modifiers TC Modifier Pricing 88161 01-183
01-016; 01-017
01-183TC
TC
TC, FP
$8.8008-083 TC, FP $8.80 88311 01-016; 01-017 TC $6.19 01-183 TC The following radiology procedure code/modifier combinations will be end-dated for the PT/Spec in the POS indicated:
Procedure Code PT/Spec Modifier(s) POS 77370 01-183 TC 22 31-All TC 11 31-All 26 11, 21, 22 77427 31-All 26 11, 21, 22 74450 31-All TC, 26 11 74775 31-All TC, 26 11 76945 31-All TC, 26 11 The following laboratory procedure code/modifiers are end-dated for PT/Spec in the POS indicated because these are not consistent with CMS payment methodology:
Procedure Code Modifiers PT/Spec POS 88150 26 31/All 11, 21, 22, 23 TC 01/016/017 23 TC 01/183 22 TC 28/280 81 88155 26 31/All 11, 21, 22, 23 TC 01/016/017 23 TC 01/183 22 TC 28/280 81 The following radiology procedure codes will have the total component (Total) and TC modifiers end-dated:
Procedure Code 74300 74301 74305 74355 75952 75953 78414 79300 The following radiology and laboratory procedure codes will have modifiers end-dated as indicated:
Procedures Code End-dated
ModifierNo Modifier
Pricing77413 TC $44.00 77414 TC $44.00 87536 U7 $116.09 The following radiology and laboratory procedure codes will have PT/Spec/modifier combinations added in POS as indicated:
Procedure
CodePT/Spec Modifier POS 76937 31/All 26 24 76937 01/183 No modifier
TC22 77427 01/183 No modifier 22 88371 01/183
01/016/017
28/280
No modifier 22
23
81
88372 01/183
01/016/017
28/280No modifier 22
23
81End-Date Places of Service
The following radiology and laboratory procedure codes will have POS 11 (office), 22, 23, 24, 31 (skilled nursing facility), 32 (nursing facility), 49 and/or 99 end-dated, as indicated, because the Department has determined that these settings are not appropriate for the performance of these services:
Procedure
CodePOS Procedure
CodePOS 70170 23, 31, 32 73040 23 73085 23 73115 23 73525 23 73580 23 73615 23 74190 23 74235 11, 23 74300 11, 22, 23, 31, 32, 49 74301 11, 22, 23, 31, 32, 49 74305 11, 22, 23, 31, 32, 49 74355 11, 22, 23, 31, 32, 49 74360 11, 23, 31, 32 74363 11, 23, 31, 32, 49 74420 31, 32 74425 11, 31, 32, 49 74450 31, 32, 49 74470 11, 23, 31, 32, 49 74775 23, 31, 32, 49 75801 11, 23, 49 75803 11, 23, 49 75805 11, 23, 49 75807 11, 23, 49 75810 11, 23, 31, 32, 49 75894 11, 23, 31, 32, 49 75896 11, 23, 31, 32, 49 75952 11, 22, 23, 99 75953 11, 22, 23, 99 75956 24 75957 24 75958 24 75959 24 75970 11, 23, 31, 32, 49 75980 11, 23, 31, 32, 49 75982 11, 23, 31, 32, 49 76120 11, 31, 32, 49 76125 11, 31, 32, 49 76932 11, 23, 31, 32, 49 76937 49 76941 11, 23, 49 76945 23, 49 76975 11, 23, 49 78608 49 78812 23 78813 23 78814 23 78815 23 78816 23 85576 23 88360 11 88361 11 Pricing Revisions
MA regulations in 55 Pa. Code § 1150.62(a) (relating to payment levels and notice of rate setting changes) set forth that the Department will establish maximum payment rates for MA covered services. The established maximum payment rates will not exceed the Medicare Upper Limit. The fees for the following procedure codes will be adjusted as follows:
Procedure Code Total TC Modifier 26 Modifier 74363 $134.46 $93.73 No Change 75894 $155.55 $94.04 No Change 76937 $25.53 No Change No Change 76975 $83.30 No Change No Change 77051 $9.71 $6.65 No Change 77052 $9.71 $6.65 No Change 77053 $56.47 $38.98 No Change 77054 $76.07 $53.50 No Change 77417 $12.92 No Fee No Fee 78811 $1,271.35 $1,207.25 No Change 78812 $1,286.78 $1,207.25 No Change 78813 $1,289.74 $1,207.25 No Change 78814 $1,297.75 $1,207.25 No Change 78815 $1,307.24 $1,207.25 No Change 78816 $1,309.62 $1,207.25 No Change 81000 $4.32 No Fee No Fee 84165 $14.65 No Fee $15.21 84181 $23.24 No Fee $15.21 84182 $24.55 No Fee $15.21 84703 $10.26 No Fee No Fee 85014 $3.23 No Fee No Fee 85018 $3.23 No Fee No Fee 85576 $29.31 No Fee $15.21 86255 $16.44 No Fee $15.21 86327 $30.95 No Fee $17.17 86701 $12.12 No Fee No Fee 86703 $18.70 No Fee No Fee 86762 $19.64 No Fee No Fee 87076 $8.75 No Fee No Fee 87210 $5.82 No Fee No Fee 87621 $47.87 No Fee No Fee 88361 $104.43 No Change No Change Limit Updates
The following radiology procedure codes will have changes to the fee schedule limits:
Procedure Code Present Limit New Limit 70170 1 2 77054 2 1 77413 10 1 Fiscal Impact
The Department anticipates minimal impact as a result of these revisions.
Public Comment
Interested persons are invited to submit written comments regarding this notice to the Department of Human Services, 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).
THEODORE DALLAS,
Acting SecretaryFiscal Note: 14-NOT-939. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 15-380. Filed for public inspection February 27, 2015, 9:00 a.m.]
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