NOTICES

DEPARTMENT OF
HUMAN SERVICES

Medical Assistance Program Fee Schedule Revisions

[53 Pa.B. 1776]
[Saturday, March 25, 2023]

 In accordance with 55 Pa. Code § 1150.61(a) (relating to guidelines for fee schedule changes), the Department of Human Services (Department) announces the additions and updates to the Medical Assistance (MA) Program Fee Schedule. These changes are effective for dates of service on and after April 1, 2023.

Background

 The Department is adding six new procedure codes to the MA Program Fee Schedule based on stakeholder request and clinical review, some of which will require prior authorization as set forth in this notice. In addition, the Department is updating four procedure codes currently on the MA Program Fee Schedule, to include provider type (PT), provider specialty (Spec), place of service (POS), modifiers and fee change revisions.

Procedure Codes Being Added

 The Department is adding the following procedure codes and procedure code with modifier combinations to the MA Program Fee Schedule. These procedure codes may include the modifiers 80 (assistant surgeon) or SG (ASC/SPU facility support component) as shown as follows:

Procedure Codes and Modifiers
58674	58674 (SG)	58674 (80)	77520
77522	77523	77525	92229

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 of certain medical assistance items and services:

Procedure Codes
77520	77522	77523	77525

Updates to Procedure Codes Currently on the MA Program Fee Schedule

Place of Service Additions

 The Department is adding combinations PT 01 (Inpatient Hospital)/Spec 183 (Hospital Based Medical Clinic)/POS 22 (Outpatient Hospital Based Clinic) and PT 31 (Physician)/Spec ALL/POS 11 (Office) for the following procedure codes:

Procedure Codes and Modifiers
52441	52442

Modifier Additions

 The Department is adding the rental (RR) modifier, with the RT (right), LT (left) or 50 (bilateral) modifier, for the procedure code indicated as follows. Procedure codes with the RR modifier require prior authorization after 3 months of rental under section 443.6(b)(3) of the code:

Procedure Codes and Modifiers
E1800 (RR) (RT)	E1800 (RR) (LT)	E1800 (RR) (50)

Fee Revision

 The regulation at 55 Pa. Code § 1150.62(a) (relating to payment levels and notice of rate setting changes) provides that the MA fee may not exceed the Medicare Upper Payment Limit. As a result, the Department revised the fee for the following procedure code:

Procedure Code	Procedure Description	Current MA Fee	Revised MA Fee
Q4186	Epifix, per sq cm	$242.96	$157.64

Fiscal Impact

 The estimated fiscal impact for fiscal year 2022-2023 is $0.694 million in total funds. The estimated annualized amount is $8.332 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, P.O. Box 2675, Harrisburg, PA 17120, RA-PWMAProgComments@pa.gov. Comments received will be reviewed and considered for any subsequent revision of 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).

VALERIE A. ARKOOSH, 
Acting Secretary

 Fiscal Note: 14-NOT-1566. (1) General Fund; (2) Implementing Year 2022-23 is $299,000; (3) 1st Succeed-ing Year 2023-24 through 5th Succeeding Year 2027-28 are $3,784,000; (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. 23-414. Filed for public inspection March 24, 2023, 9:00 a.m.]

---

No part of the information on this site may be reproduced for profit or sold for profit.

This material has been drawn directly from the official Pennsylvania Bulletin full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.

---