NOTICES

DEPARTMENT OF
HUMAN SERVICES

Medical Assistance Program Fee Schedule Revisions; 2022 Healthcare Common Procedure Coding System Updates; Prior Authorization Requirements

[52 Pa.B. 5015]
[Saturday, August 13, 2022]

 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 29, 2022.

 The Department is adding and end-dating procedure codes as a result of implementing the 2022 updates published by the Centers for Medicare & Medicaid Services (CMS) 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 setting limitations. 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 2022 HCPCS updates. These procedure codes may include the modifiers 80 (assistant surgeon), SG (ASC/SPU facility support component), RT (right), LT (left), 50 (bilateral) or 26 (professional component).

Procedure Codes and Modifiers
01937	01938	01939	01940	01941
01942	63052	63052 (80)	63053	63053 (80)
66989 (SG)	66989 (RT)	66989 (LT)	66989 (50)	66991 (SG)
66991 (RT)	66991 (LT)	66991 (50)	68841 (SG)	68841 (RT)
68841 (LT)	68841 (50)	69716	69716 (SG)	69719
69719 (SG)	69726	69726 (SG)	69727	69727 (SG)
82653	83521	86015	86036	86037
86051	86052	86053	86231	86362
86363	86596	90626	90627	90671
90677	90759	93319	93593 (SG)	93593 (26)
93594 (SG)	93594 (26)	93595 (SG)	93595 (26)	93596 (SG)
93596 (26)	93597 (SG)	93597 (26)	93598 (26)	99424
99426	D3921	D3921 (SG)	D9947	D9948
D9949	G1028

 The Department is adding the following procedure codes, and procedure code and modifier combinations to the MA Program Fee Schedule based upon clinical review or provider request. These procedure codes may include modifiers SG, 26, TC (technical component) or NU (purchase).

Procedure Codes and Modifiers
52441	52441 (SG)	52442	81415	81417
90587	93325	93325 (TC)	93325 (26)	95800
95800 (TC)	95800 (26)	0014M	B4105	D4346
D4346 (SG)	L8619 (NU)	L8692 (NU)	L8694	Q4186

 The Department is end-dating the following procedure codes from the MA Program Fee Schedule as a result of the 2022 HCPCS updates:

Procedure Codes
01935	01936	21310	33470	33722
43850	43855	59135	63194	63195
63196	63198	63199	69715	69718
76101	76102	92561	92564	93530
93531	93532	93533	93561	93562
G2064	G2065

Prior Authorization Requirements

 The following procedure codes being added to the MA Program Fee Schedule require prior authorization, under section 443.6(b)(7) of the Human Services Code (code) (62 P.S. § 443.6(b)(7)) regarding reimbursement for certain medical assistance items and services:

Procedure Codes
81415	81417	B4105	Q4186

 The following dental procedure codes being added to the MA Program Fee Schedule require prior authorization, under section 443.6(b)(5) of the code:

Procedure Codes
D3921	D9947

 The following prosthetic procedure code and modifier combinations being added to the MA Program Fee schedule require prior authorization, under section 443.6(b)(1) of the code:

Procedure Codes and Modifiers
L8619 (NU)	L8692 (NU)	L8694

Additional Procedure Code for Take-Home Supplies of Naloxone

 The Department is adding G1028 as an additional add-on procedure code to the MA Program Fee Schedule to track the dispensing of take-home supplies of Naloxone by a provider.

 The Department is opening Provider Type (PT)/Specialty (Spec)/Place of Service (POS) combination 08 (Clinic)/110 (Psychiatric Outpatient Clinic)/49 (Independent Clinic) for procedure code G1028.

 The Department is opening PT/Spec/POS combination 08 (Clinic)/184 (Outpatient Drug and Alcohol)/57 (Non-Residential Substance Abuse Treatment Facility) for procedure code G1028.

 The Department is also updating the procedure code description for procedure code G2215 as the National code description was changed with the annual update to include dosage units.

Procedure Code	Old Procedure Code Description	New Procedure Code Description
G2215	Take home supply of nasal naloxone (provision of the services by a Medicare enrolled opioid treatment program); list separately in addition to code for primary procedure	Take home supply of nasal naloxone; 2-pack of 4 mg per 0.1 ml nasal spray (provision of the services by a Medicare-enrolled Opioid Treatment Program); list separately in addition to code for primary procedure

Updates to Procedure Codes Currently on the MA Program Fee Schedule

Physicians' Services

 The Department is adding the RT, LT or 50 modifiers, or both, with or without the 80 modifier, for PT/Spec/POS combination 31 (Physician)/All/21 (Inpatient Hospital) for the following procedure codes as the procedures may be performed unilaterally or bilaterally, with or without an assistant surgeon:

Procedure Codes and Modifiers
27078 (RT)	27078 (LT)	27078 (50)	27078 (80) (RT)	27078 (80) (LT)
27078 (80) (50)	27140 (RT)	27140 (LT)	27140 (50)	27140 (80) (RT)
27140 (80) (LT)	27140 (80) (50)	27147 (RT)	27147 (LT)	27147 (50)
27147 (80) (RT)	27147 (80) (LT)	27147 (80) (50)	27151 (RT)	27151 (LT)
27151 (50)	27151 (80) (RT)	27151 (80) (LT)	27151 (80) (50)	27226 (RT)
27226 (LT)	27226 (50)	27226 (80) (RT)	27226 (80) (LT)	27226 (80) (50)
27227 (RT)	27227 (LT)	27227 (50)	27227 (80) (RT)	27227 (80) (LT)
27227 (80) (50)	27228 (RT)	27228 (LT)	27228 (50)	27228 (80) (RT)
27228 (80) (LT)	27228 (80) (50)	27245 (RT)	27245 (LT)	27245 (50)
27245 (80) (RT)	27245 (80) (LT)	27245 (80) (50)	27405 (RT)	27405 (LT)
27405 (50)	27405 (80) (RT)	27405 (80) (LT)	27405 (80) (50)	27407 (RT)
27407 (LT)	27407 (50)	27407 (80) (RT)	27407 (80) (LT)	27407 (80) (50)
27507 (RT)	27507 (LT)	27507 (50)	27507 (80) (RT)	27507 (80) (LT)
27507 (80) (50)	27514 (RT)	27514 (LT)	27514 (50)	27514 (80) (RT)
27514 (80) (LT)	27514 (80) (50)	29826 (RT)	29826 (LT)	29826 (80) (RT)
29826 (80) (LT)	49491 (RT)	49491 (LT)	49491 (50)	49491 (80) (RT)
49491 (80) (LT)	49491 (80) (50)	49492 (RT)	49492 (LT)	49492 (50)
49492 (80) (RT)	49492 (80) (LT)	49492 (80) (50)	69535 (RT)	69535 (LT)
69535 (50)

 The Department is removing the 50 modifier for PT/Spec/POS combination 31/All/21 for surgical procedure code 32442 as clinical review has determined this procedure may not be performed bilaterally.

 The Department is updating units or service limitations, or both, to the following surgical procedure codes as a result of clinical review:

Procedure Codes	Present Unit Limit	New Unit Limit	Present Limit	New Limit
29826	1:2	1:1	Twice per day	Once per day
49491	1:1	1:2	Once per day	Once per right side and once per left side, per day
49492	1:1	1:2	Once per day	Once per right side and once per left side, per day

 The Department is making limit changes to the following surgical procedure codes as a result of clinical review:

Procedure Code	Present Limit	New Limit
30160	None	Once per lifetime
32442	2 per lifetime	Once per lifetime
44157	None	Once per lifetime
44158	None	Once per lifetime
45121	None	Once per lifetime
49250	None	Once per lifetime
51925	None	Once per lifetime
52649	None	Once per lifetime
55801	None	Once per lifetime
55821	2 per lifetime	Once per lifetime
69535	None	Once per right side and once per left side, per lifetime

 The Department is adding POS 12 (Home) for PT/Spec 09 (Certified Registered Nurse Practitioner)/All and 31/All for procedure code 99188. Additionally, the Department is changing the maximum age for this procedure code from 4 years of age to 20 years of age.

 The Department is end-dating PT/Spec/POS combinations 01 (Inpatient Facility)/All/23 (Emergency Room) and 01/183 (Hospital Based Medical Clinic)/22 (Outpatient Hospital) for the following procedure codes as a result of clinical review and the Department's determination that this setting is not appropriate for the performance of these services:

Procedure Codes
27405	27407	27514
29826	30160	49492

 The Department is end-dating POS 11 (Office), 23 (Emergency Room) or 99 (Special Treatment Room), or both, for PT/Spec 31/All for the following procedure codes as a result of clinical review and the Department's determination that this setting is not appropriate for the performance of these services:

Procedure Codes	End-Dated POS
27405	23, 99
27407	23, 99
27514	23, 99
29826	23, 99
30160	11, 23, 99

 The Department is end-dating PT/Spec 27 (Dentist)/All for POS 11, 21, 22, 24 (Ambulatory Surgical Center (ASC)) and 49 for surgical procedure code 30160 and opening PT/Spec 27/272 (oral/maxillofacial surgeon) in POS 21 and 24 with and without modifier 80 as a result of clinical review.

 The Department is removing modifier 80 for procedure code 69535 as a result of clinical review and the Department's determination that this procedure is not appropriate for an assistant surgeon.

Ambulatory Surgical Center/Short Procedure Unit (SPU) Services

 The Department is opening PT/Spec combination 01/021 (SPU) in POS 24 for the procedure codes identified as follows with the SG modifier as clinical review determined these procedure codes can be performed safely in a SPU depending on the procedure and will be paid the facility support component fee of $776:

Procedure Codes and Modifiers
27078 (SG)	27140 (SG)	27147 (SG)	27151 (SG)	27226 (SG)
27227 (SG)	27228 (SG)	27245 (SG)	27507 (SG)	49492 (SG)

 The Department is adding POS 24 for PT/Spec 31/All for the following procedure codes as a result of clinical review.

Procedure Codes
27078	27140	27147	27151	27226
27227	27228	27245	27507

 The Department is adding the RT, LT or 50 modifiers, or both, with or without the 80 modifier, for PT/Spec/POS combination 31/All/24 for these procedure codes as these procedures may be performed unilaterally or bilaterally with or without an assistant surgeon.

Procedure Codesand Modifiers
27078 (RT)	27078 (LT)	27078 (50)	27078 (80) (RT)	27078 (80) (LT)
27078 (80) (50)	27140 (RT)	27140 (LT)	27140 (50)	27140 (80) (RT)
27140 (80) (LT)	27140 (80) (50)	27147 (RT)	27147 (LT)	27147 (50)
27147 (80) (RT)	27147 (80) (LT)	27147 (80) (50)	27151 (RT)	27151 (LT)
27151 (50)	27151 (80) (RT)	27151 (80) (LT)	27151 (80) (50)	27226 (RT)
27226 (LT)	27226 (50)	27226 (80) (RT)	27226 (80) (LT)	27226 (80) (50)
27227 (RT)	27227 (LT)	27227 (50)	27227 (80) (RT)	27227 (80) (LT)
27227 (80) (50)	27228 (RT)	27228 (LT)	27228 (50)	27228 (80) (RT)
27228 (80) (LT)	27228 (80) (50)	27245 (RT)	27245 (LT)	27245 (50)
27245 (80) (RT)	27245 (80) (LT)	27245 (80) (50)	27405 (RT)	27405 (LT)
27405 (50)	27405 (80) (RT)	27405 (80) (LT)	27405 (80) (50)	27407 (RT)
27407 (LT)	27407 (50)	27407 (80) (RT)	27407 (80) (LT)	27407 (80) (50)
27507 (RT)	27507 (LT)	27507 (50)	27507 (80) (RT)	27507 (80) (LT)
27507 (80) (50)	27514 (RT)	27514 (LT)	27514 (50)	27514 (80) (RT)
27514 (80) (LT)	27514 (80) (50)	29826 (RT)	29826 (LT)	29826 (80) (RT)
29826 (80) (LT)	49491 (RT)	49491 (LT)	49491 (50)	49491 (80) (RT)
49491 (80) (LT)	49491 (80) (50)	49492 (RT)	49492 (LT)	49492 (50)
49492 (80) (RT)	49492 (80) (LT)	49492 (80) (50)

 The Department is end-dating PT/Spec/POS combinations 01/021/24 or 02 (ASC)/020(ASC)/24, or both, for procedure code 29826 with the SG modifier as these settings were determined to be clinically inappropriate for this service.

Clinic Services

 The Department is end-dating PT/Spec/POS combination 08/All/49 for the following procedure codes as a result of clinical review and the Department's determination that this setting is not appropriate for the performance of these services.

Procedure Codes
27405	27407	27514
29286	30160	49492

Laboratory Services

 The Department is adding the QW (Clinical Laboratory Improvement Amendments (CLIA) waived test) informational modifier to laboratory procedure code 87801, which CMS identifies as a CLIA waived test.

Procedure Code	PT/Spec/POS	Modifier
87801	01/16 (Emergency Room Arrangement 1)/23	QW
	01/17 (Emergency Room Arrangement 2)/23	QW
	01/183/22	QW
	28 (Laboratory)/280 (Independent Laboratory)/81 (Independent Laboratory)	QW

 The Department is adding the following PT/Spec/POS combinations and modifiers, as indicated as follows, to laboratory procedure code 87801 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	Modifiers
87801	08/082 (Independent Medical/Surgical Clinic)/49	No modifier and QW
	09/All/11	No modifier and QW
	10/100/11	No modifier and QW
	31/All/11	No modifier and QW
	33 (Certified Nurse Midwife)/335(Certified Nurse Midwife)/11	No modifier and QW

Fiscal Impact

 The estimated cost for Fiscal Year 2022-2023 is $6.137 million in total funds. The estimated annualized cost is $9.205 million in total 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 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 Secretary

 Fiscal Note: 14-NOT-1523. (1) General Fund; (2) Implementing Year 2022-23 is $2,946,000; (3) 1st Succeeding Year 2023-24 through 5th Succeeding Year 2027-28 are $4,324,000; (4) 2021-22 Program—$644,059,000; 2020-21 Program—$808,350,000; 2019-20 Program—$344,107,000; (7) MA—Fee-for-Service; (8) recommends adoption. Funds have been included in the budget to cover this increase.

[Pa.B. Doc. No. 22-1223. Filed for public inspection August 12, 2022, 9:00 a.m.]

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