Pennsylvania Bulletin

PA Bulletin, Doc. No. 23-702

NOTICES

DEPARTMENT OF HUMAN SERVICES

Medical Assistance Program Fee Schedule Revisions for Evaluation and Management Procedure Codes

[53 Pa.B. 2906]
[Saturday, May 27, 2023]

In accordance with 55 Pa. Code § 1150.61(a) (relating to guidelines for fee schedule changes), the Department of Human Services (Department) announces updates to the Medical Assistance (MA) Program Fee Schedule for Evaluation and Management (E&M) procedure codes, including making adjustments to the fees for some procedure codes. These updates are effective for dates of service on and after June 1, 2023.

Background

The Department is end-dating procedure codes, updating descriptions and making fee adjustments on procedure codes as a result of implementing the 2023 updates published by the Centers for Medicare & Medicaid Services to the 2023 Healthcare Common Procedure Coding System (HCPCS). The Department is also making changes to procedure codes currently on the MA Program Fee Schedule, including adding or removing Provider Type (PT)/Specialty (Spec) combinations, Place of Service (POS) and procedure code modifiers.

Procedure Codes Being End-dated

The Department is end-dating the following procedure codes from the MA Program Fee Schedule as a result of the 2023 HCPCS Updates:

Procedure Codes

99217 99218 99219 99220 99224

99225 99226 99241 99251 99281

99318 99324 99325 99326 99327

99328 99334 99335 99336 99337

99343

Updates to E&M Procedure Codes Currently on the MA Program Fee Schedule

PT/Spec/POS Updates

The Department is adding PT/Spec/POS combinations for the following procedure codes with and without modifiers, as indicated as follows, as the Department determined these provider types and specialties are appropriate for these services:

Procedure Code and Modifiers Addition of PT/Spec/POS

99238 (FQ-audio-only service) 31 (Physician)/339 (Psychiatry)/02 (Telehealth Provided Other than in Patient's Home)

99239 (FQ) 31/339/02

99252 18/180/0218 (Optometrist)/180 (Optometrist)/02
18/180/21 (Inpatient Hospital)
18/180/22 (Outpatient Hospital)

99253 18/180/02
18/180/21
18/180/22

99344 09 (Certified Registered Nurse Practitioner)/ALL/12 (Home)
10 (Mid-Level Practitioner)/100 (Physician Assistant)/12
14 (Podiatrist)/140 (Podiatrist)/12
31/ALL/12
33 (Certified Nurse Midwife)/335 (Certified Nurse Midwife)/12

99344 (TH-obstetric) 09/ALL/12
10/100/12
31/ALL/12
33/335/12

99345 09/ALL/12
10/100/12
14/140/12
31/ALL/12
33/335/12

99345 (TH) 09/ALL/12
10/100/12
31/ALL/12
33/335/12

99350 09/ALL/12
10/100/12
14/140/12

99350 (TH) 09/ALL/12
10/100/12

The Department is updating the PT/Spec combinations for the following procedure codes, as indicated as follows, as the Department determined these provider types and specialties are appropriate for these services:

Procedure Code Current PT/Spec New PT/Spec
Effective
June 1, 2023

99239 27 (Dentist)/272 (Oral/Maxillofacial Surgeon)
27/283 (Cleft Palate) 27/ALL

99252 14/ALL 14/140

99253 14/ALL 14/140

99254 14/ALL 14/140

99255 14/ALL 14/140

99347 09/093 (Nurse Practitioner) 09/ALL

99348 09/093 09/ALL

99349 09/093 09/ALL

99460 09/093
09/094 (Family Home Health)
09/101 (Neonatal)
09/105 (Pediatric Acute Chronic)
09/106 (Pediatric Critical Care)
09/297 (Pediatric Oncology)
09/298 (Perinatal)
09/299 (Women's Health) 09/ALL

99463 09/093
09/094
09/101
09/105
09/106
09/297
09/298
09/299 09/ALL

Healthy Beginnings Plus (HBP) Program

The Department is opening the following PT/Spec/POS combinations for procedure code 99242 with U9 (pricing) and HD (pregnant/parenting women's program) modifiers, as 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 99241.

Procedure Code
and Modifiers New PT/Spec POS

99242
(U9) (HD) 01 (Inpatient Facility)/183
(Hospital Based Medical Clinic) 02, 10 (Telehealth provided in Patient's Home), 22

05 (Home Health)/050 (Home Health Agency) 02, 10, 12

08 (Clinic)/080 (Federally Qualified Health Center) 02, 10, 12, 50 (Federally Qualified Health Center)

08/081 (Rural Health Clinic) 02, 10, 12, 72 (Rural Health Clinic)

08/082 (Independent Medical/Surgical Center) 02, 10, 49 (Independent Clinic)

08/083 (Family Planning Clinic) 02, 10, 22, 49

31/ALL 02, 10, 11 (Office), 12, 99 (Other Unlisted)

33/335 02, 10, 11, 99

47 (Birthing Center)/470 (Birthing Center) 02, 10, 11, 25 (Birthing Center)

Psychiatric Outpatient and Drug and Alcohol Clinic Services

The Department is opening the following PT/Spec/POS combinations for procedure code 99242 with U7 (pricing) or UB (pricing) modifiers, as indicated as follows, to allow for the billing of services that were previously billed with the end-dated procedure code 99241. The Department is not revising the fee for procedure code 99242 with these modifiers.

Procedure
Code and
Modifiers Code Description Addition of
PT/Spec/POS

99242 (U7) Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. (Chemotherapy clinic visit for administration and evaluation of drugs other than methadone or drugs for opiate detox) 08/184 (Outpatient Drug and Alcohol Clinic)/57 (Non-Residential Substance Abuse Treatment Facility)

99242 (UB) Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. (Psychiatric clinic medication visit for drug administration and evaluation) 08/074 (Mobile Mental Health Treatment)/15 (Mobile Unit)

08/110 (Psychiatric Outpatient Clinic)/49

Other PT/Spec Updates

The Department is end-dating PT/Spec/POS combinations for the following procedure codes with and without modifiers, as indicated as follows, as the Department determined these provider types and specialties are not appropriate for these services:

Procedure Codes End-dated PT/Spec/POS

99306 18/180/02
18/180/31 (Skilled Nursing Facility)
18/180/32 (Nursing Facility)

99310 18/180/02
18/180/31
18/180/32

99341
99341 (FQ) 31/339/10

99342
99342 (FQ) 31/339/10

99344 15 (Chiropractor)/150 (Chiropractor)/02
15/150/12

99345 15/150/02
15/150/12

99349 15/150/02
15/150/12
18/180/02
18/180/12

99350 15/150/02
15/150/12

99492
99492 (FQ) 31/339/10

99493
99493 (FQ) 31/339/10

99494
99494 (FQ) 31/339/10

Modifier Updates

The Department is adding the Q6 (Informational) modifier used to identify nonemergency visits to the emergency room when used in combination with the following procedure code, as indicated as follows. This procedure code may include the emergency room modifiers U4 (pricing) or U5 (pricing).

Procedure Code
and Modifiers PT/Spec POS

99283 (U4) (Q6) 01/016 (Emergency Room Arrangement 1)
01/017 (Emergency Room Arrangement 2) 02, 23 (Emergency Room)

99283 (U5) (Q6) 01/016
01/017 02, 23

The Department is adding the TH modifier for the PT/Spec combination 31/ALL to be used to identify prenatal or postpartum obstetric evaluation and management services only, for the following procedure codes:

Procedure Code and Modifiers

99234 (TH) 99235 (TH) 99236 (TH) 99239 (TH)

The Department is end-dating the 54 (surgical care) modifier for T1015 procedure code with the PT/Spec combinations 08/080 and 08/081.

The Department is end-dating the GT (telemedicine) modifier for the following procedure codes, as a result of the addition of POS 02 or 10 to indicate the use of telemedicine:

Procedure Codes

99050 99202 99203 99204 99205

99211 99212 99213 99214 99215

99234 99235 99236 99238 99239

99242 99243 99244 99245 99252

99253 99254 99255 99282 99283

99284 99285 99341 99342 99344

99345 99347 99348 99349 99350

99381 99382 99383 99384 99385

99386 99387 99391 99392 99393

99394 99395 99396 99397 99483

99484 99491 99492 99493 99494

99501 T1015

The Department is end-dating the HA (child/adolescent program) modifier and modifier combinations U4, U1 (informational) and U5, U1 when used with procedure code T1015.

The Department is end-dating the U1 modifier for the PT/Spec/POS combinations 31/ALL/02, 11, and/or 99 for the following procedure codes.

Procedure Codes

99203 99204 99211 99212

99213 99214 99215

The Department is end-dating the U9 modifier for the following procedure codes as the U9 modifier will no longer be needed for the PT/Spec combination 15/150:

Procedure Codes

99341 99342 99347 99348

POS Updates

The Department is adding POS 10, used to identify when telehealth is provided in the patient's home, for the following procedure codes for all PT/Spec combinations as the Department determined this setting is appropriate for the performance of these services using telemedicine:

Procedure Codes with Addition of POS 10

99202 99203 99204 99205 99211

99212 99213 99214* 99215* 99242

99243 99244 99245 99304 99305

99306 99307 99308 99309 99310

99315 99316 99401 99407 99483

99484

*Note: For procedure codes 99214 and 99215, the Department will not be adding POS 10 when used for services related to Healthy Beginnings Plus.

The Department is adding POS 02 or POS 10 to the T1015 procedure code with and without modifiers in the following PT/Spec combinations as the Department determined these settings are appropriate for the performance of these services:

Procedure Code and Modifiers PT/Spec with Addition of POS 02 or POS 10

T1015 (U4)
T1015 (U4) (FP-family planning)
T1015 (U5)
T1015 (U5) (FP)
T1015 (U7)
T1015 (U7) (GN-speech pathology)
T1015 (U7) (GO-occupational therapy)
T1015 (U7) (GP-physical therapy)
T1015 (U8-pricing)
T1015 (U8) (GN)
T1015 (U8) (GO)
T1015 (U8) (GP) 01/183/10

T1015 (U3-vision) 08/080/02

T1015
T1015 (AE-childhood nutrition and weight management services)
T1015 (FP)
T1015 (HR-childhood nutrition and weight management services)
T1015 (TJ-childhood nutrition and weight management services)
T1015 (TJ) (TS-childhood nutrition and weight management services)
T1015 (TS)
T1015 (TT-childhood nutrition and weight management services)
T1015 (U3)
T1015 (U9) 08/080/10

T1015 (U3) 08/081/02

T1015
T1015 (AE)
T1015 (FP)
T1015 (HR)
T1015 (TJ)
T1015 (TJ) (TS)
T1015 (TS)
T1015 (TT)
T1015 (U3)
T1015 (U9) 08/081/10

T1015 (TH)
T1015 (U7)
T1015 (U7) (FP)
T1015 (U7) (GN)
T1015 (U7) (GO)
T1015 (U7) (GP) 08/082/10

The Department is adding the POS 21 used to identify when services are provided in the inpatient hospital setting, for the following procedure codes, as the Department determined this setting is clinically appropriate for these services:

Procedure Codes with Addition of POS 21

99234 99235 99236

The Department is adding the POS 22 for the purposes of observation, based on the revisions to the National code descriptions as a result of the 2023 HCPCS Updates, for the following procedure codes:

Procedure Codes with Addition of POS 22

99221 99222 99223 99231

99232 99233 99238 99239

99252 99253 99254 99255

The Department is end-dating the POS 02 for all provider types for the following procedure codes as the Department determined that this setting is not appropriate for these services:

Procedure Codes

99050 99291 99292 99341 99342

99344 99345 99347 99348 99349

99350 99360 99381 99382 99383

99384 99385 99386 99387 99391

99392 99393 99394 99395 99396

99397 99460 99461 99462 99463

99468 99469 99471 99472 99475

99476 99477 99478 99479 99480

99492 99493 99494 99501

The Department is end-dating POS 02 for the following procedure codes with modifier combinations, as indicated as follows, as the Department determined that this setting is not appropriate for these services:

Procedure Code and Modifiers

99214 (U9) (HD) 99215 (U9) (HD) T1015 (EP-EPSDT)

Due to the National code description revisions as a result of the 2023 HCPCS Updates, consultations while in observation may be billed using procedure codes 99252, 99253, 99254 and 99255. Therefore, the Department is end-dating the POS 22 for the PT 14 and PT 31 for the following procedure codes:

Procedure Codes

99242 99243 99244 99245

The Department is end-dating POS 31 and POS 32 for all of the PT/Spec combinations for the following procedure codes:

Procedure Codes

99252 99253 99254 99255

The Department is end-dating POS 33 (Custodial Care Facility) for all of the PT/Spec combinations for procedure code 99483, as providers can now bill POS 12 when the services are completed in the home.

The Department is end-dating POS 54 (Intermediate Care Facility) for all of the PT/Spec combinations for the following procedure codes:

Procedure Codes

99242 99243 99244 99245

Code Description and Fee Updates

The Department is updating the procedure code descriptions, as indicated as follows, as a result of changes to the National code descriptions made as part of the 2023 HCPCS Updates. The Department is also adjusting the MA Program fees for the procedure codes identified as follows, effective June 1, 2023.

Procedure
Code and
Modifiers New Code Description
Effective June 1, 2023 Current
Fee MA Fee
Effective
June 1, 2023

99221
99221 (TH) Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. $79 $65.05

99222
99222 (TH) Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded. $106.37 $101.94

99223
99223 (TH) Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. $156.63 $135.92

99231
99231 (TH) Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded. $30.06 $38.93

99232
99232 (TH) Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. $56.22 $61.98

99233
99233 (TH) Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. $80.79 $93.26

99234 Hospital inpatient or observation, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. $69.18 $77.36

99235 Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded. $86.29 $124.85

99236 Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded. $111.46 $163.65

99238 Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter. $17 $63.10

99239 Hospital inpatient or observation discharge day management; more than 30 minutes on the date of the encounter. $73.26 $89.53

99242 Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. $55.15 $43.90

99243 Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. $76.93 $69.46

99244 Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. $120.56 $105.94

99245 Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded. $151.44 $141.97

99252 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. $30 $56.27

99253 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. $30 $78.42

99254 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. $49 $109.02

99255 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 80 minutes must be met or exceeded. $49 $146.47

99282
99282 (TH) Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. $26.85 $32.98

99283
99283 (TH) Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. $35 $56.65

99284
99284 (TH) Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. $50 $95.33

99285
99285 (TH) Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. $50 $138.74

99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded. $43.75 $62.84

99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. $56.15 $104.06

99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. $69.92 $142.27

99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. $23.29 $30.83

99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. $36.65 $57.94

99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. $51.27 $83.07

99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. $60.31 $119.53

99315 Nursing facility discharge management; 30 minutes or less total time on the date of the encounter. $36.58 $63.61

99316 Nursing facility discharge management; more than 30 minutes total time on the date of the encounter. $47.94 $102.54

99341 Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. $21 $38.21

99341 (TH) $26

99342 Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. $21 $61.11

99342 (TH) $26

99344 Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. $13 $112.58

99345 Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. $13 $158.12

99347
99347 (TH) Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. $21 $34.99

99348
99348 (TH) Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. $26 $59.58

99349 Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. $31 $99.66

99349 (TH) $36

99350
99350 (TH) Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. $36 $145.47

99483 Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements: Cognition-focused evaluation including a pertinent history and examination, Medical decision making of moderate or high complexity, Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity, Use of standardized instruments for staging of dementia (eg, functional assessment staging test (FAST), clinical dementia rating (CDR)), Medication reconciliation and review for high-risk medications, Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s), Evaluation of safety (eg, home), including motor vehicle operation, Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks, Development, updating or revision, or review of an Advance Care Plan, Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neuro-cognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support. Typically, 60 minutes of total time is spent on the date of the encounter. $140.87 $151.71

Fiscal Impact

The estimated annualized cost beginning in Fiscal Year 2023-2024 is $12.461 million in total funds.

Public Comment

Interested persons are invited to submit written comments regarding the E&M procedure code updates 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-1580. Under section 612 of The Administrative Code of 1929 (71 P.S. § 232), (1) General Fund; (2) Implementing Year 2022-23 is $0; (3) 1st Succeeding Year 2023-24 through 5th Succeeding Year 2027-28 are $5,658,000; (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. The impact in the outyears will be included in the budget.

[Pa.B. Doc. No. 23-702. Filed for public inspection May 26, 2023, 9:00 a.m.]

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Procedure Codes
99217	99218	99219	99220	99224
99225	99226	99241	99251	99281
99318	99324	99325	99326	99327
99328	99334	99335	99336	99337
99343

Procedure Code and Modifiers	Addition of PT/Spec/POS
99238 (FQ-audio-only service)	31 (Physician)/339 (Psychiatry)/02 (Telehealth Provided Other than in Patient's Home)
99239 (FQ)	31/339/02
99252	18/180/0218 (Optometrist)/180 (Optometrist)/02 18/180/21 (Inpatient Hospital) 18/180/22 (Outpatient Hospital)
99253	18/180/02 18/180/21 18/180/22
99344	09 (Certified Registered Nurse Practitioner)/ALL/12 (Home) 10 (Mid-Level Practitioner)/100 (Physician Assistant)/12 14 (Podiatrist)/140 (Podiatrist)/12 31/ALL/12 33 (Certified Nurse Midwife)/335 (Certified Nurse Midwife)/12
99344 (TH-obstetric)	09/ALL/12 10/100/12 31/ALL/12 33/335/12
99345	09/ALL/12 10/100/12 14/140/12 31/ALL/12 33/335/12
99345 (TH)	09/ALL/12 10/100/12 31/ALL/12 33/335/12
99350	09/ALL/12 10/100/12 14/140/12
99350 (TH)	09/ALL/12 10/100/12

Procedure Code	Current PT/Spec	New PT/Spec Effective June 1, 2023
99239	27 (Dentist)/272 (Oral/Maxillofacial Surgeon) 27/283 (Cleft Palate)	27/ALL
99252	14/ALL	14/140
99253	14/ALL	14/140
99254	14/ALL	14/140
99255	14/ALL	14/140
99347	09/093 (Nurse Practitioner)	09/ALL
99348	09/093	09/ALL
99349	09/093	09/ALL
99460	09/093 09/094 (Family Home Health) 09/101 (Neonatal) 09/105 (Pediatric Acute Chronic) 09/106 (Pediatric Critical Care) 09/297 (Pediatric Oncology) 09/298 (Perinatal) 09/299 (Women's Health)	09/ALL
99463	09/093 09/094 09/101 09/105 09/106 09/297 09/298 09/299	09/ALL

Procedure Code and Modifiers	New PT/Spec	POS
99242 (U9) (HD)	01 (Inpatient Facility)/183 (Hospital Based Medical Clinic)	02, 10 (Telehealth provided in Patient's Home), 22
	05 (Home Health)/050 (Home Health Agency)	02, 10, 12
	08 (Clinic)/080 (Federally Qualified Health Center)	02, 10, 12, 50 (Federally Qualified Health Center)
	08/081 (Rural Health Clinic)	02, 10, 12, 72 (Rural Health Clinic)
	08/082 (Independent Medical/Surgical Center)	02, 10, 49 (Independent Clinic)
	08/083 (Family Planning Clinic)	02, 10, 22, 49
	31/ALL	02, 10, 11 (Office), 12, 99 (Other Unlisted)
	33/335	02, 10, 11, 99
	47 (Birthing Center)/470 (Birthing Center)	02, 10, 11, 25 (Birthing Center)

Procedure Code and Modifiers	Code Description	Addition of PT/Spec/POS
99242 (U7)	Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. (Chemotherapy clinic visit for administration and evaluation of drugs other than methadone or drugs for opiate detox)	08/184 (Outpatient Drug and Alcohol Clinic)/57 (Non-Residential Substance Abuse Treatment Facility)
99242 (UB)	Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. (Psychiatric clinic medication visit for drug administration and evaluation)	08/074 (Mobile Mental Health Treatment)/15 (Mobile Unit)
08/110 (Psychiatric Outpatient Clinic)/49

Procedure Codes	End-dated PT/Spec/POS
99306	18/180/02 18/180/31 (Skilled Nursing Facility) 18/180/32 (Nursing Facility)
99310	18/180/02 18/180/31 18/180/32
99341 99341 (FQ)	31/339/10
99342 99342 (FQ)	31/339/10
99344	15 (Chiropractor)/150 (Chiropractor)/02 15/150/12
99345	15/150/02 15/150/12
99349	15/150/02 15/150/12 18/180/02 18/180/12
99350	15/150/02 15/150/12
99492 99492 (FQ)	31/339/10
99493 99493 (FQ)	31/339/10
99494 99494 (FQ)	31/339/10

Procedure Code and Modifiers	PT/Spec	POS
99283 (U4) (Q6)	01/016 (Emergency Room Arrangement 1) 01/017 (Emergency Room Arrangement 2)	02, 23 (Emergency Room)
99283 (U5) (Q6)	01/016 01/017	02, 23

Procedure Codes
99050	99202	99203	99204	99205
99211	99212	99213	99214	99215
99234	99235	99236	99238	99239
99242	99243	99244	99245	99252
99253	99254	99255	99282	99283
99284	99285	99341	99342	99344
99345	99347	99348	99349	99350
99381	99382	99383	99384	99385
99386	99387	99391	99392	99393
99394	99395	99396	99397	99483
99484	99491	99492	99493	99494
99501	T1015

Procedure Code and Modifiers	PT/Spec with Addition of POS 02 or POS 10
T1015 (U4) T1015 (U4) (FP-family planning) T1015 (U5) T1015 (U5) (FP) T1015 (U7) T1015 (U7) (GN-speech pathology) T1015 (U7) (GO-occupational therapy) T1015 (U7) (GP-physical therapy) T1015 (U8-pricing) T1015 (U8) (GN) T1015 (U8) (GO) T1015 (U8) (GP)	01/183/10
T1015 (U3-vision)	08/080/02
T1015 T1015 (AE-childhood nutrition and weight management services) T1015 (FP) T1015 (HR-childhood nutrition and weight management services) T1015 (TJ-childhood nutrition and weight management services) T1015 (TJ) (TS-childhood nutrition and weight management services) T1015 (TS) T1015 (TT-childhood nutrition and weight management services) T1015 (U3) T1015 (U9)	08/080/10
T1015 (U3)	08/081/02
T1015 T1015 (AE) T1015 (FP) T1015 (HR) T1015 (TJ) T1015 (TJ) (TS) T1015 (TS) T1015 (TT) T1015 (U3) T1015 (U9)	08/081/10
T1015 (TH) T1015 (U7) T1015 (U7) (FP) T1015 (U7) (GN) T1015 (U7) (GO) T1015 (U7) (GP)	08/082/10

Procedure Codes with Addition of POS 22
99221	99222	99223	99231
99232	99233	99238	99239
99252	99253	99254	99255

Procedure Codes
99050	99291	99292	99341	99342
99344	99345	99347	99348	99349
99350	99360	99381	99382	99383
99384	99385	99386	99387	99391
99392	99393	99394	99395	99396
99397	99460	99461	99462	99463
99468	99469	99471	99472	99475
99476	99477	99478	99479	99480
99492	99493	99494	99501

Procedure Code and Modifiers	New Code Description Effective June 1, 2023	Current Fee	MA Fee Effective June 1, 2023
99221 99221 (TH)	Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.	$79	$65.05
99222 99222 (TH)	Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.	$106.37	$101.94
99223 99223 (TH)	Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.	$156.63	$135.92
99231 99231 (TH)	Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.	$30.06	$38.93
99232 99232 (TH)	Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.	$56.22	$61.98
99233 99233 (TH)	Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded.	$80.79	$93.26
99234	Hospital inpatient or observation, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.	$69.18	$77.36
99235	Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded.	$86.29	$124.85
99236	Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.	$111.46	$163.65
99238	Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter.	$17	$63.10
99239	Hospital inpatient or observation discharge day management; more than 30 minutes on the date of the encounter.	$73.26	$89.53
99242	Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.	$55.15	$43.90
99243	Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.	$76.93	$69.46
99244	Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.	$120.56	$105.94
99245	Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.	$151.44	$141.97
99252	Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.	$30	$56.27
99253	Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.	$30	$78.42
99254	Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.	$49	$109.02
99255	Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 80 minutes must be met or exceeded.	$49	$146.47
99282 99282 (TH)	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.	$26.85	$32.98
99283 99283 (TH)	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making.	$35	$56.65
99284 99284 (TH)	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.	$50	$95.33
99285 99285 (TH)	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making.	$50	$138.74
99304	Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.	$43.75	$62.84
99305	Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.	$56.15	$104.06
99306	Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.	$69.92	$142.27
99307	Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.	$23.29	$30.83
99308	Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.	$36.65	$57.94
99309	Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.	$51.27	$83.07
99310	Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.	$60.31	$119.53
99315	Nursing facility discharge management; 30 minutes or less total time on the date of the encounter.	$36.58	$63.61
99316	Nursing facility discharge management; more than 30 minutes total time on the date of the encounter.	$47.94	$102.54
99341	Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.	$21	$38.21
99341 (TH)	$26
99342	Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.	$21	$61.11
99342 (TH)	$26
99344	Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.	$13	$112.58
99345	Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.	$13	$158.12
99347 99347 (TH)	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.	$21	$34.99
99348 99348 (TH)	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.	$26	$59.58
99349	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.	$31	$99.66
99349 (TH)	$36
99350 99350 (TH)	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.	$36	$145.47
99483	Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements: Cognition-focused evaluation including a pertinent history and examination, Medical decision making of moderate or high complexity, Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity, Use of standardized instruments for staging of dementia (eg, functional assessment staging test (FAST), clinical dementia rating (CDR)), Medication reconciliation and review for high-risk medications, Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s), Evaluation of safety (eg, home), including motor vehicle operation, Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks, Development, updating or revision, or review of an Advance Care Plan, Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neuro-cognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support. Typically, 60 minutes of total time is spent on the date of the encounter.	$140.87	$151.71

NOTICES

DEPARTMENT OF HUMAN SERVICES

Medical Assistance Program Fee Schedule Revisions for Evaluation and Management Procedure Codes

[53 Pa.B. 2906][Saturday, May 27, 2023]

[Pa.B. Doc. No. 23-702. Filed for public inspection May 26, 2023, 9:00 a.m.]

[53 Pa.B. 2906]
[Saturday, May 27, 2023]