NOTICES
DEPARTMENT OF HUMAN SERVICES
Medical Assistance Program Fee Schedule Revisions; 2018 Healthcare Common Procedure Coding System Updates; Prior Authorization Requirements
[48 Pa.B. 3901]
[Saturday, June 30, 2018]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 July 2, 2018.
The Department is adding and end-dating procedure codes as a result of implementing the 2018 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 2018 HCPCS updates:
Procedure Codes and Modifiers
00731 00732 00811 00812 00813 15730 15730 (SG) 15733 15733 (SG) 31241 (RT) 31241 (LT) 31241 (50) 31253 (SG) 31253 (RT) 31253 (LT) 31253 (50) 31257 (SG) 31257 (RT) 31257 (LT) 31257 (50) 31259 (SG) 31259 (RT) 31259 (LT) 31259 (50) 31298 (SG) 31298 (RT) 31298 (LT) 31298 (50) 33927 33927 (80) 33928 33928 (80) 33929 33929 (80) 34701 34701 (80) 34702 34702 (80) 34703 34703 (80) 34704 34704 (80) 34705 34705 (80) 34706 34706 (80) 34707 (RT) 34707 (LT) 34707 (50) 34707 (80) (RT) 34707 (80) (LT) 34707 (80) (50) 34708 (RT) 34708 (LT) 34708 (50) 34708 (80) (RT) 34708 (80) (LT) 34708 (80) (50) 34709 34709 (80) 34710 34710 (80) 34711 34711 (80) 34712 34712 (80) 34713 34713 (80) 34714 34714 (80) 34715 34715 (80) 34716 34716 (80) 36465 (SG) 36465 (RT) 36465 (LT) 36465 (50) 36466 (SG) 36466 (RT) 36466 (LT) 36466 (50) 38222 38222 (SG) 38573 38573 (SG) 38573 (80) 43286 43286 (80) 43287 43287 (80) 43288 43288 (80) 58575 58575 (80) 71045 71045 (TC) 71045 (26) 71046 71046 (TC) 71046 (26) 71047 71047 (TC) 71047 (26) 71048 71048 (TC) 71048 (26) 74018 74018 (TC) 74018 (26) 74019 74019 (TC) 74019 (26) 74021 74021 (TC) 74021 (26) 81105 86008 86794 87634 87634 (QW) 87662 94617 94617 (TC) 94617 (26) 94618 94618 (TC) 94618 (26) 95249 96573 96574 97127 99483 D5511 D5512 D5611 D5612 D5621 D5622 D9222 D9239 E0953 (NU) E0953 (RR) E0954 (NU) E0954 (RR) J7296 (FP) K0553 K0554 (NU) K0554 (RR) K0903 (RT) K0903 (LT) K0903 (50) L3761 (RT) L3761 (LT) L3761 (50) L8625 (NU) The Department is adding the following procedure codes, and procedure code and modifier combinations to the MA Program Fee Schedule based upon provider requests or clinical review:
Procedure Codes and Modifiers
33361 33362 33363 33364 33365 33366 33367 33368 33369 44705 79005 79005 (TC) 79005 (26) 79101 79101 (TC) 79101 (26) 79445 (26) 82044 82044 (QW) 90739 90750 95251 96161 D1354 D1354 (SG) G0455 G0455 (SG) For additional information regarding dental procedure code D1354, see MA Bulletin 27-18-08, ''Medical Assistance Program Dental Fee Schedule Update,'' effective July 2, 2018.
The Department is end-dating the following procedure codes from the MA Program Fee Schedule as a result of the 2018 HCPCS updates:
Procedure Codes
00740 00810 01180 01190 01682 15732 29582 29583 31320 34800 34802 34803 34804 34805 34825 34826 34900 36120 36515 55450 69820 69840 71010 71015 71020 71021 71022 71023 71030 71034 71035 74000 74010 74020 75658 75952 75953 75954 77422 78190 83499 86729 86822 87277 87470 88154 94620 97532 D5510 D5610 D5620 G0202 G0204 G0206 G0364 No new authorizations will be issued for the procedure codes being end-dated on and after July 2, 2018. For any of the previously listed procedure codes that had a prior authorization issued before July 2, 2018, 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 July 2, 2019, for those services that were prior authorized.
Prior Authorization Requirements
Laboratory procedure code 86008 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)). Information regarding the Department's prior authorization process may be viewed in the MA Provider Handbook and is available at http://www.dhs.pa.gov/publications/forproviders/promiseproviderhandbooksandbillingguides/index.htm.
The following durable medical equipment (DME) procedure code and modifier combinations being added to the MA Program Fee Schedule will require prior authorization after 3 months of rental as authorized under section 443.6(b)(3) of the code:
Procedure Codes and Modifiers
E0953 (RR) E0954 (RR) Medical supply procedure code K0553 being added to the MA Program Fee schedule will require prior authorization, as authorized under section 443.6(b)(7) of the code.
DME procedure code K0554 (NU) being added to the MA Program Fee Schedule require prior authorization under section 443.6(b)(2) of the code.
DME procedure code K0554 (RR) being added to the MA Program Fee Schedule will require prior authorization for the first month's rental under section 443.6(b)(3) of the code.
The following prosthetic and orthotic 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 and Modifiers
L3761 (RT) L3761 (LT) L3761 (50) L8625 (NU) Updates to Procedure Codes Currently on the MA Program Fee Schedule
Physician Services
The Department is opening Provider Type (PT)/Specialty (Spec) combination 31 (physician)/All and end-dating PT 31 specialties 318 (General Practitioner), 319 (Surgery), 322 (Internal Medicine) and 328 (Obstetrics and Gynecology), in Place of Service (POS) 21 (Inpatient Hospital) for the following surgical procedure codes, as the Department has determined that it is appropriate for all physician specialties to perform these services:
Procedure Codes
58291 58292 The Department is end-dating ''All'' specialties for PT 01 (Inpatient Facility) in POS 23 (Emergency Room) and for PT 08 (Clinic) in POS 49 (Independent Clinic) for surgical procedure code 36430 and opening individual specialties as explained as follows:
Procedure Code End-dated PT/Spec/POS Opened PT/Spec/POS Reason 36430 01/All/23 01/017/23 Emergency room arrangement 2 must bill for services provided by the emergency
room physician.08/All/49 08/082/49 The Department has determined that other settings are not appropriate for this physician service. ASC/SPU Services
The Department is end-dating ''All'' specialties for PT 01 and PT 02 (Ambulatory Surgical Center (ASC)) for surgical procedure code 36430 because Department review determined that this procedure is not appropriate for all specialties.
For the surgical procedure codes identified as follows that are currently on the MA Program Fee Schedule, the Department is adding the SG (facility support component) modifier, POS 24 (ASC) and PT/Spec combinations 01/021 (Short Procedure Unit (SPU)), 02/020 (ASC), or both. These procedure codes can be performed safely in an SPU, ASC, or both, depending on the procedure, and will be paid the facility support component fee of $776:
Procedure Code New PT/Spec New POS New Modifier 36430 01/021; 02/020 24 SG 58260 02/020 24 SG 58262 01/021; 02/020 24 SG 58263 01/021; 02/020 24 SG 58270 01/021; 02/020 24 SG 58291 01/021 24 SG 58292 01/021 24 SG Dental Services
The following dental procedure codes have limit or description changes, or both, (in bold), due to the addition of new procedure codes D9222 and D9238 for the initial 15-minute increment of service:
Procedure Code Old Limit New Limit Procedure Description D9223 3 2 Deep sedation/general anesthesia—each subsequent 15 minute increment D9243 2 2 Intravenous moderate (conscious) sedation/analgesia—each subsequent 15 minute increment For further information on updates to dental procedure codes, see MA Bulletin 27-18-08, ''Medical Assistance Program Dental Fee Schedule Update,'' effective July 2, 2018.
Modifier Updates
QW Modifier
The Department is adding the QW (Clinical Laboratory Improvement Amendments (CLIA) waived test) informational modifier, the FP (Family Planning) modifier or the 91 (Repeat Clinical Diagnostic Laboratory Test), or both, modifier, when applicable, to the following procedure codes and the PT/Spec/POS combinations on the MA Program Fee Schedule for laboratory tests that CMS identifies as CLIA waived tests. For additional information, see MA Bulletin 01-12-67, ''Clinical Laboratory Improvement Amendments Requirements'' which may be viewed at http://www.dhs.pa.gov/publications/bulletinsearch/bulletinselected/index.htm?bn=01-12-67.
Procedure Code PT/Spec/POS Modifiers 85025 01/016/23 (Emergency Room Arrangement 1) QW; QW 91 01/017/23 (Emergency Room Arrangement 2) QW; QW 91 01/012/22 (Medical Rehab Hospital) QW; QW 91 01/014/22 (Inpatient Medical Rehab Unit) QW; QW 91 01/019/22 (Drug and Alcohol Rehab Hospital) QW; QW 91 01/183/22 (Outpatient Hospital Clinic) QW; QW FP; FP 91; QW 91; QW FP 91 01/441/22 (Drug and Alcohol Rehab Unit) QW; QW 91 08/083/22 (Outpatient Family Planning Clinic) QW FP; FP 91; QW FP 91 08/083/49 (Independent Family Planning Clinic) QW FP; FP 91; QW FP 91 28/280/81 (Independent Laboratory) QW; QW FP; FP 91; QW 91; QW FP 91 The Department is also adding the PT/Spec/POS and modifiers, as indicated as follows, to the following laboratory procedure code 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 85025 08/082/49 (Independent Medical/Surgical Clinic) No modifier; 91; FP; QW; FP 91; QW FP; QW 91; QW FP 91 09/All/11 (Certified Registered Nurse Practitioner) No modifier; 91; FP; QW; FP 91; QW FP; QW 91; QW FP 91 31/All/11 (Physician) No modifier; 91; FP; QW; FP 91; QW FP; QW 91; QW FP 91 33/335/11 (Certified Nurse Midwife) No modifier; 91; FP; QW; FP 91; QW FP; QW 91; QW FP 91 Limit Updates Limit Updates
Laboratory procedure code 85025 has a limitation update as indicated as follows:
Procedure Code Old Limit New Limit Reason 85025 1:1 1:2 This procedure can now be repeated once per day, so the maximum limit has been increased to reflect this change. Open Places of Service
The Department is opening POS 24 for the following procedure codes and PT/Spec combinations, with or without pricing modifier 80 (Assistant Surgeon), as indicated as follows, as the Department determined that these settings are appropriate for the performance of these services:
Procedure Code PT/Spec POS 58262
58262 (80)31/All 24 58263
58263 (80)31/All 24 58270
58270 (80)31/All 24 58291
58291 (80)31/All 24 58292
58292 (80)31/All 24 Service Limits
The MA Program has established service limits for some of these procedure codes. When a provider determines that an 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.
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 before implementing the limits.
Fiscal Impact
The estimated fiscal impact in Fiscal Year 2018-2019 is a savings of $0.374 million ($0.179 million in State funds and $0.195 million in Federal funds). The estimated annualized fiscal impact is a savings of $0.449 million ($0.215 million in State funds and $0.234 in Federal 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).
TERESA D. MILLER,
SecretaryFiscal Note: 14-NOT-1257. No fiscal impact; this action will result in nominal estimated savings; (8) recommends adoption.
[Pa.B. Doc. No. 18-1008. Filed for public inspection June 29, 2018, 9:00 a.m.]
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