NOTICES
DEPARTMENT OF
HUMAN SERVICES
Medical Assistance Program Fee Schedule Revisions; Prior Authorization Requirements; Unit and Service Limitation Updates; Fee Adjustments
[54 Pa.B. 5680]
[Saturday, September 7, 2024]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 September 9, 2024, unless otherwise noted.
The Department is adding new procedure codes based on clinical review, provider requests and recommendations from the Advisory Committee on Immunization Practices (ACIP) and the United States Food and Drug Administration (FDA). The Department is also making changes to prior authorization requirements as a result of clinical review. Additionally, the Department is making changes to procedure codes currently on the MA Program Fee Schedule as a result of clinical review and provider requests which include updates to units, limits and fee adjustments.
Procedure Codes Being Added
Effective for dates of service on and after June 17, 2024, the Department added the following procedure code to the MA Program Fee Schedule for vaccine administration based upon FDA approval and ACIP recommendation. Providers should follow the ACIP recommendations and package insert to determine the correct population, dosage and instructions for administration of all vaccines.
Procedure Code MA Fee 90684 $10 Effective for dates of services on and after August 1, 2024, the Department added the following procedure codes to the MA Program Fee Schedule for vaccine administration based upon FDA approval, ACIP recommendation, clinical review or provider request. Providers should follow the ACIP recommendations and package insert to determine the correct population, dosage and instructions for administration of all vaccines.
Procedure Codes MA Fee 90653 $10 90657 $10 90658 $10 90660 $10 90661 $10 90673 $10 The Department is adding the following procedure codes to the MA Program Fee Schedule based upon clinical review and provider request. These procedure codes may include the modifiers RR (rental), UD (informational), RT (right), LT (left) or FP (Family Planning). The procedure code descriptions for procedure codes with the UD informational modifier indicate a post administration observation period of 2 hours.
Procedure Codes MA Fee E0604 (RR) $67.97 G2082 (UD) $34.10 G2083 (UD) $34.10 L8033 (RT) $926.83 L8033 (LT) $926.83 L8039 (RT) $1,436.36 L8039 (LT) $1,436.36 S0199 $690 S0199 (FP) $690 S8427 (RT) $55.20 S8427 (LT) $55.20 Prior Authorization Requirement Updates
The following procedure codes being added to the MA Program Fee Schedule require prior authorization, as set forth in section 443.6(b)(1) of the Human Services Code (62 P.S. § 443.6(b)(1)).
Procedure Codes L8033 (RT) L8033 (LT) L8039 (RT) L8039 (LT) The Department removed prior authorization requirements for the following procedure codes with or without the NU (purchase) or RR modifiers, based on clinical review.
Procedure Codes and Modifiers 92065 E0570 (NU) E0570 (RR) E0572 (NU) E0572 (RR) E0574 (RR) Unit and Limit Updates
The Department is updating the unit limitations for the following procedure codes based upon clinical review.
Procedure Codes Former Minimum/
Maximum
Unit LimitNew Minimum/
Maximum
Unit LimitL8001
L80021:1 1:4 L8010 1:4 1:2 S8424
S84281:3 1:2 The Department is updating limits for the following procedure codes based upon clinical review.
Procedure
CodeFormer Limit New Limit L8000 4 per calendar month 4 per 365 days L8001 N/A 4 per 365 days L8002 N/A 4 per 365 days L8010 4 per calendar month 3 per RT side and 3 per LT side, per 180 days L8015 N/A 4 per 365 days Fee Adjustments
The Department is adjusting the MA Program fees for the following procedure codes when submitted with or without a modifier as indicated as follows.
Procedure Codes Former Fee New Fee 59840 $81.50 $765 59841 $306 $1,000 59850 $246 $340 59856 $454.94 $1,000 65426 $224 $454.08 90868 $19.89 $104.87 90869 $83.89 $168.89 A4280 $3.66 $7.07 L8000 $28 $42.79 L8001 $78.99 $144.35 L8002 $103.90 $189.82 L8010 (RT) $32.04 $42.56 L8010 (LT) $32.04 $42.56 L8015 $35.66 $68.98 L8020 (RT) $150 $293.25 L8020 (LT) $150 $293.25 L8030 (RT) $142.03 $379.54 L8030 (LT) $142.03 $379.54 L8031 (RT) $142.03 $379.54 L8031 (LT) $142.03 $379.54 L8032 (RT) $27.75 $45.08 L8032 (LT) $27.75 $45.08 L8035 (RT) $2,179.14 $4,215.60 L8035 (LT) $2,179.14 $4,215.60 S8424 (RT) $24.50 $60.16 S8424 (LT) $24.50 $60.16 S8428 (RT) $6 $36.82 S8428 (LT) $6 $36.82 Fiscal Impact
The estimated cost for Fiscal Year 2024-2025 is $2.948 million in total funds. The estimated annualized cost is $5.053 million in total funds.
Public Comment
Interested persons are invited to submit written comments to the Department of Human Services, Office of Medical Assistance Programs, c/o Regulations Coordinator, P.O. Box 2675, Harrisburg, PA 17120, RA-PWMAProg Comments@pa.gov. Comments received within 30 days 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 at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
VALERIE A. ARKOOSH,
SecretaryFiscal Note: 14-NOT-1647. Under section 612 of The Administrative Code of 1929 (71 P.S. § 232), (1) General Fund; (2) Implementing Year 2024-25 is $1,324,000; (3) 1st Succeeding Year 2025-26 through 5th Succeeding Year 2029-30 are $2,237,000; (4) 2023-24 Program—$697,354,000; 2022-23 Program—$589,137,000; 2021-22 Program—$644,059,000; (7) MA—Fee-for-Service; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 24-1268. Filed for public inspection September 6, 2024, 9:00 a.m.]
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