NOTICES
DEPARTMENT OF
HUMAN SERVICES
Medical Assistance Program Fee Schedule Revisions; 2021 Healthcare Common Procedure Coding System Updates and Fee Adjustments; Prior Authorization Requirements
[51 Pa.B. 5914]
[Saturday, September 11, 2021]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 23, 2021.
The Department is adding and end-dating procedure codes as a result of implementing the 2021 updates published by the Centers for Medicare & Medicaid Services to the Healthcare Common Procedure Coding System (HCPCS). The Department is also adding other procedure codes and making changes to procedure codes currently on the MA Program Fee Schedule, to include fee adjustments. As follows, some of the procedure codes being added to the MA Program Fee Schedule will require prior authorization.
Procedure Codes Being Added or End-dated
The Department is adding the following procedure codes, and procedure code and modifier combinations to the MA Program Fee Schedule as a result of the 2021 HCPCS updates. These procedure codes may include the modifiers SG (ASC/SPU facility support component), 80 (assistant surgeon), 26 (professional component) or TC (technical component).
Procedure Codes and Modifiers
30468 30468 (SG) 32408 32408 (SG) 33741 33741 (80) 33745 33745 (80) 33746 33746 (80) 71271 71271 (26) 71271 (TC) 80189 81168 81279 92650 92651 92652 92653 94619 94619 (26) 94619 (TC) D1321 D3471 D3471 (SG) D3472 D3472 (SG) D3473 D3473 (SG) D3501 D3501 (SG) D3502 D3502 (SG) D3503 D3503 (SG) D7961 D7961 (SG) D7962 D7962 (SG) G2213 G2214 G2215 G2216 The Department is end-dating the following procedure codes from the MA Program Fee Schedule as a result of the 2021 HCPCS updates:
Procedure Codes
19324 19366 32405 49220 57112 58293 61870 62163 63180 63182 69605 76970 78135 92585 92586 92992 92993 94250 94400 94750 94770 95071 99201 D7960 G0297 The Department is adding the following procedure codes, and procedure code and modifier combinations to the MA Program Fee Schedule based upon clinical review. These procedure codes may include modifiers 26, TC and FP (Family Planning).
Procedure Codes and Modifiers
87510 87510 (FP) 90471 90472 93351 93351 (26) 93351 (TC) A9274
Prior Authorization Requirements
For the following procedure codes, and procedure code and modifier combinations being added to the MA Program Fee Schedule, which are advanced radiology services, the Department will require prior authorization, under section 443.6(b)(7) of the Human Services Code (code) (62 P.S. § 443.6(b)(7)). The process for obtaining prior authorization is described in MA Bulletin 01-14-42, titled ''Advanced Radiologic Imaging Services,'' which may be viewed online at https://www.dhs.pa.gov/providers/FAQs/Documents/MA%20Bulletin%2001-14-42.pdf.
Procedure Codes and Modifiers
71271 71271 (26) 71271 (TC) The following procedure codes being added to the MA Program Fee Schedule require prior authorization, as authorized under section 443.6(b)(7) of the code:
Procedure Codes and Modifiers
81168 81279 The following dental procedure codes, and procedure codes and modifier combinations being added to the MA Program Fee Schedule require prior authorization, as authorized under section 443.6(b)(5) of the code:
Procedure Codes and Modifiers
D3471 D3471 (SG) D3472 D3472 (SG) D3473 D3473 (SG) D3501 D3501 (SG) D3502 D3502 (SG) D3503 D3503 (SG) Procedure Codes for Take-Home Supplies of Naloxone
The Department is adding G2215 and G2216 as add-on procedures to the MA Program Fee Schedule to track the dispensing of take-home supplies of Naloxone. In order to identify when take-home supplies of Naloxone are dispensed, providers should use G2215 or G2216 in addition to one of the following procedure codes that are currently open on the MA Program Fee Schedule:
Procedure Codes
99202 99203 99204 99205 99211 99212 99213 99214 99215 99281 99282 99283 99284 99285 T1015 Updates to Procedure Codes Currently on the MA Program Fee Schedule
Physicians' Services
The GT (telemedicine) modifier is being removed for the following procedure codes and POS 02 (telemedicine) is being added for providers to identify when these services are provided by means of telemedicine.
Procedure Codes
99221 99222 99223 99231 99232 99233 99241 The Department is adjusting the MA Program fee for the evaluation and management procedure codes identified as follows, effective August 23, 2021.
Procedure Codes Code Description Current Fee New Fee 99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the problems requiring admission are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit. $29.50 $79 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the problems requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. $29.50 $106.37 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the problems requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. $42 $156.63 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit. $17 $30.06 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. $17 $56.22 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. $17 $80.79 Ambulatory Surgical Center (ASC)/Short Procedure Unit (SPU) Services
The Department is opening Provider Type (PT)/Specialty (Spec) combinations 01/021 (SPU), 02/020 (ASC), or both for the procedure codes identified as follows in Place of Service (POS) 24 (ASC) with the SG modifier as clinical review determined these procedure codes can be performed safely in a SPU, ASC, or both, depending on the procedure, and will be paid the facility support component fee of $776:
Procedure Code New PT/Spec POS 19307 (SG) 01/021 24 27486 (SG) 01/021 24 63055 (SG) 01/021
02/02024 The Department is adding POS 24 for PT/Spec 31 (Physician)/All for the following procedure code and modifier combinations as a result of clinical review and the Department's determination that this setting is appropriate for the performance of these services. These procedure codes include modifiers 80, RT (right), LT (left) or 50 (bilateral), or both.
Procedure Code
19307 (RT) 19307 (LT) 19307 (50) 19307 (80) (RT) 19307 (80) (LT) 19307 (80) (50) 27486 (RT) 27486 (LT) 27486 (50) 27486 (80) (RT) 27486 (80) (LT) 27486 (80) (50) 63055 63055 (80) Laboratory Services
The Department is adding the FP modifier for the following laboratory procedure code, as determined by clinical review, in the PT/Spec/POS combinations as indicated as follows:
Procedure Code New Modifier PT/Spec POS 87480 FP 01/183 (Hospital Based Medical Clinic) 22 (Outpatient Hospital) 08/083 (Family Planning Clinic) 22, 49 (Independent Clinic) 28/280 (Independent Laboratory) 81 (Independent Laboratory) The Department is opening the following laboratory procedure codes with the FP modifier for PT/Spec combination 08/083 in POS 22 and 49, as determined by clinical review, indicated as follows:
Procedure Code and Modifier
87660 (FP) 87661 (FP) The following laboratory procedure code has unit and service limitation updates with and without the FP modifier as a result of clinical review and National Correct Coding Initiative edits indicated as follows:
Procedure Code Old Unit Limit New Unit Limit Present Limit New Limit 87480 1:2 1:1 Twice per day Once per day Healthy Beginnings Plus (HBP) Program
The Department is opening the following PT/Spec/POS combinations for procedure code 99241 with U9 (pricing) and HD (pregnant/parenting women's program) modifiers, indicated as follows, to allow for the billing of services provided in the HBP Program that were previously billed with the end-dated procedure code 99201.
Procedure Code New PT/Spec POS 99241 (U9) (HD) 01/183 02, 22 05/050 (Home Health Agency) 02, 12 (Home) 08/080 (FQHC) 02, 12, 50 (FQHC) 08/081(RHC) 02, 12, 72 (RHC) 08/082 (Independent Medical/ Surgical Clinic) 02, 49 08/083 02, 22, 49 31/All 02, 11 (Office), 12, 99 (Special Treatment Room) 33/335 (Certified Nurse Midwives) 02, 11, 99 47/470 (Birth Center) 02, 11, 25 (Birth Center) Psychiatric Outpatient and Drug and Alcohol Clinic Services
The Department is opening the following PT/Spec/POS combinations for procedure code 99241 with U7 (pricing) or UB (pricing) modifiers, indicated as follows, to allow for the billing of services that were previously billed with the end-dated procedure code 99201.
Procedure Code Code Description New PT/Spec POS 99241 (U7) Office consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the presenting problems are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient or family. (Chemotherapy clinic visit for administration and evaluation of drugs other than methadone or drugs for opiate detox.) 08/184 (Outpatient Drug and Alcohol) 57 (Nonresidential Substance Abuse Treatment Facility) 99241 (UB) Office consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling or coordination of care, or both, with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patient's or family's needs, or both. Usually, the presenting problems are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient or family, or both. (Psychiatric clinic medication visit for drug administration and evaluation.) 08/110 (Psychiatric Outpatient Clinic) 49 08/074 (Mobile Mental Health) 15 (Mobile Unit) Durable Medical Equipment and Medical Supplies
The Department is changing the limitations for medical supply procedure code E0603 (NU) from ''once per lifetime'' to ''once per calendar year'' based on clinical review. This procedure code with the NU modifier still requires prior authorization for purchase, under section 443.6(b)(2) of the code. Additionally, the Department is updating the fee for the medical supply procedure code indicated as follows.
Procedure Code Description Current Fee New Fee E0603 (NU) Breast pump, electric (AC or DC, or both), any type $267.53 $180 Fiscal Impact
The estimated cost for Fiscal Year 2021-2022 is $3.944 million. The estimated annualized fiscal impact is $5.916 million.
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 Regulations Coordinator, 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 Hamilton Relay Service (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
MEG SNEAD,
Acting SecretaryFiscal Note: 14-NOT-1462. (1) General Fund; (2) Implementing Year 2021-22 is $1,866,000; (3) 1st Succeeding Year 2022-23 through 5th Succeeding Year 2026-27 are $2,810,000; (4) 2020-21 Program—$808,350,000; 2019-20 Program—$344,107,000; 2018-19 Program—$342,544,000; (7) MA—Fee-for-Service; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 21-1541. Filed for public inspection September 10, 2021, 9:00 a.m.]
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