NOTICES
DEPARTMENT OF HUMAN SERVICES
Medical Assistance Program Fee Schedule Revisions; 2017 Healthcare Common Procedure Coding System Updates; Prior Authorization Requirements
[47 Pa.B. 4595]
[Saturday, August 5, 2017]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 August 7, 2017.
The Department is adding and end-dating procedure codes as a result of implementing the 2017 updates made by the Centers for Medicare & Medicaid Services (CMS) to the Healthcare Common Procedure Coding System (HCPCS). The Department is also adding and end-dating other procedure codes and making changes to procedure codes currently on the MA Program Fee Schedule. 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.
Procedure Codes Being Added or End-dated
The Department is adding the following procedure code and modifier combinations to the MA Program Fee Schedule as a result of the 2017 HCPCS updates:
Procedure Codes and Modifiers
27197 27197 (SG) 27198 27198 (SG) 28291 (SG) 28291 (RT) 28291 (LT) 28291 (50) 28291 (80) (RT) 28291 (80) (LT) 28291 (80) (50) 28295 (SG) 28295 (RT) 28295 (LT) 28295 (50) 28295 (80) (RT) 28295 (80) (LT) 28295 (80) (50) 31551 31551 (SG) 31552 31552 (SG) 31553 31553 (SG) 31554 31554 (SG) 31572 (SG) 31572 (RT) 31572 (LT) 31572 (50) 31573 (SG) 31573 (RT) 31573 (LT) 31573 (50) 31574 (SG) 31574 (RT) 31574 (LT) 31574 (50) 31591 31591 (SG) 31592 33390 33390 (80) 33391 33391 (80) 36456 36901 36901 (SG) 36902 36902 (SG) 36903 36903 (SG) 36904 36904 (SG) 36905 36905 (SG) 36906 36906 (SG) 36907 36908 36909 37246 37246 (SG) 37247 37248 37248 (SG) 37249 62320 62320 (SG) 62321 62321 (SG) 62322 62322 (SG) 62323 62323 (SG) 62324 62324 (SG) 62325 62325 (SG) 62326 62326 (SG) 62327 62327 (SG) 76706 76706 (TC) 76706 (26) 77065 77065 (TC) 77065 (26) 77066 77066 (TC) 77066 (26) 77067 77067 (TC) 77067 (26) 80305 80305 (QW) 80306 80307 81413 81414 84410 84410 (FP) 90682 92242 92242 (TC) 92242 (26) 96160 96160 (FP) 96377 97161 (U8) 97162 (U8) 97163 (U8) 97164 97165 (U8) 97166 (U8) 97167 (U8) 97168 99151 99152 99152 (FP) 99153 99153 (FP) 99155 99156 99156 (FP) 99157 99157 (FP) A4224 A4225 A4553 G0499 G0499 (FP) G0659 L1851 (RT) L1851 (LT) L1851 (50) L1852 (RT) L1852 (LT) L1852 (50) The Department is adding the following procedure code and modifier combinations to the MA Program Fee Schedule based upon provider requests or clinical review:
Procedure Codes and Modifiers
44203 44203 (80) 44205 44205 (80) 81512 90625 T2101 The Department is end-dating the following procedure codes from the MA Program Fee Schedule as a result of the 2017 HCPCS updates:
Procedure Codes
11752 21495 22305 27193 27194 28290 28293 28294 31582 31588 33400 33401 33403 35450 35458 35471 35472 35475 35476 36147 36148 36870 62310 62311 62318 62319 75791 75962 75964 75966 75968 75978 77051 77052 77055 77056 77057 80300 80301 80302 80303 80304 81280 81281 81282 92140 93965 97001 97002 97003 97004 B9000 G0437 G0477 G0478 G0479 K0901 K0902 S8032 No new authorizations will be issued for the procedure codes being end-dated on and after August 7, 2017. For any of the previously listed procedure codes that had a prior authorization issued before August 7, 2017, 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 August 7, 2018, for those services that were previously prior authorized.
Prior Authorization Requirements
The following laboratory procedure codes being added to the MA Program Fee Schedule will require prior authorization, as authorized under section 443.6(b)(7) of the Human Services Code (code) (62 P.S. § 443.6(b)(7)), and as described in the MA Provider Handbook which may be viewed online at http://www.dhs.pa.gov/publications/forproviders/promiseproviderhandbooksandbillingguides/index.htm#.VxaJ1E32ZtQ.
Procedure Codes
81413 81414 81512 The Department will require prior authorization of procedure code T2101 for pasteurized donor human milk being added to the MA Program Fee Schedule, as authorized under section 443.6(b)(7) of the code.
The following orthoses procedure code and modifier combinations being added to the MA Program Fee Schedule will require prior authorization, as authorized under section 443.6(b)(1) of the code:
Procedure Codes
L1851 (RT) L1851 (LT) L1851 (50) L1852 (RT) L1852 (LT) L1852 (50) Updates to Procedure Codes Currently on the MA Program Fee Schedule
Modifier Updates
QW Modifier
The Department is adding the QW (Clinical Laboratory Improvement Amendments (CLIA) waived test) informational modifier and QW with the Family Planning (FP) modifier, when applicable, to the following procedure codes and the Provider Type (PT)/Specialty (Spec)/Place of Service (POS) combinations on the MA Program Fee Schedule for laboratory tests that CMS identifies as CLIA waived tests. This information is described in MA Bulletin 01-12-67, Clinical Laboratory Improvement Amendments Requirements, which may be viewed online at http://www.dhs.pa.gov/publications/bulletinsearch/bulletinselected/index.htm?bn=01-12-67#.VxaDYE32ZtQ.
Procedure Code PT/Spec/POS Modifiers 87633 01/016/23 (emergency room arrangement 1) QW 01/017/23 (emergency room arrangement 2) QW 01/183/22 (outpatient hospital clinic) QW 28/280/81 (independent laboratory) QW G0472 01/183/22 QW; QW FP 28/280/81 QW; QW FP The Department is also adding the PT/Spec/POS and modifiers, as indicated, to the following laboratory procedure codes on the MA Program Fee Schedule as a result of the latest tests listed by CMS as CLIA waived tests.
Procedure Code PT/Spec/POS Modifier 86803 08/082/49 (independent medical/surgical clinic) No modifier; QW; FP; QW FP 08/083/22 (outpatient family planning clinic) FP; QW FP 08/083/49 (independent family planning clinic) FP; QW FP 09/All/11 (certified registered nurse practitioner) No modifier; QW; FP; QW FP 31/All/11 (physician) No modifier; QW; FP; QW FP 33/335/11 (certified nurse midwife) No modifier; QW; FP; QW FP 87633 08/082/49 No modifier; QW 09/All/11 No modifier; QW 31/All/11 No modifier; QW 33/335/11 No modifier; QW G0472 08/082/49 No modifier; QW; FP; QW FP 08/083/22 FP; QW FP 08/083/49 FP; QW FP 09/All/11 No modifier; QW; FP; QW FP 31/All/11 No modifier; QW; FP; QW FP 33/335/11 No modifier; QW; FP; QW FP Open Places of Service
The Department is opening POS 22 (outpatient hospital) for the following procedure codes and PT/Spec combinations, as indicated, as the Department has determined that these settings are appropriate for the performance of these services:
Procedure Code PT/Spec POS 99241 14/140 (podiatrist)
31/All22 99242 14/140
31/All22 99243 14/140
31/All22 99244 14/140
31/All22 99245 14/140
31/All22 End-Date Places of Service
The Department is end-dating POS 21 (inpatient hospital) for the following procedure codes and PT/Spec combination 27 (Dentist)/All because the service is performed only in the outpatient setting:
Procedure Codes
99241 99242 99243 99244 99245 Service Limits
The MA Program has established service limits for some of these procedure codes. When a provider determines that a MA beneficiary is in need of a service or item in excess of the established limits, the provider may request a waiver of the limits through the 1150 Administrative Waiver (Program Exception) process. For instructions on how to apply for a Program Exception, refer to the provider handbook at http://www.dhs.pa.gov/publications/forproviders/promiseproviderhandbooksandbillingguides/index.htm#.Vyj_vk32ZtR.
Managed Care Delivery System
MA Managed Care Organizations (MCO) are not required to impose the service limits that apply in the MA Fee-for Service (FFS) delivery system, although they are permitted to do so. MA MCOs may not impose service limits that are more restrictive than the service limits established in the MA FFS delivery system. An MA MCO that chooses to establish service limits must notify their network providers and members of the limits before implementing the limits.
Fiscal Impact
The estimated cost for Fiscal Year 2017-2018 is $0.522 million ($0.252 million in State funds). The estimated cost for Fiscal Year 2018-2019 is $0.696 million ($0.335 million in State funds).
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,
SecretaryFiscal Note: 14-NOT-1169. (1) General Fund; (2) Implementing Year 2017-18 is $252,000; (3) 1st Succeeding Year 2018-19 through 5th Succeeding Year 2022-23 are $335,000; (4) 2016-17 Program—$450,970,000; 2015-16 Program—$392,918,000; 2014-15 Program—$564,772,000; (7) MA—FFS; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 17-1308. Filed for public inspection August 4, 2017, 9:00 a.m.]
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