Pennsylvania Bulletin

PA Bulletin, Doc. No. 05-2413

NOTICES

Medical Assistance Program Fee Schedule Revisions to Procedure Codes for Prostheses, Orthoses and Medical Supplies

[35 Pa.B. 7066]

   The Department of Public Welfare (Department) announces the addition to the Medical Assistance (MA) Program Fee Schedule of procedure codes for prostheses, orthoses and medical supplies and the accompanying prior authorization requirements.

Fee Schedule Additions

   The Pennsylvania Orthotic and Prosthetic Society requested that the Department review a list of prostheses, orthoses and medical supply codes that have been requested frequently through the 1150 Administrative Waiver Process (Program Exception). See 55 Pa. Code § 1150.63 (relating to waivers). As a result of this review, effective for dates of service on and after December 5, 2005, the Department is adding procedure codes for prostheses, orthoses and medical supplies to the MA Program Fee Schedule.

   Fees for the added procedure codes will be published in a Medical Assistance Bulletin.

   The following procedure codes that are being added to the MA Program Fee Schedule do not require prior authorization:

A5500 RT LT 50 For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multidensity insert(s), per shoe.

A5503 RT LT 50 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe.

A5504 RT LT 50 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe.

A5505 RT LT 50 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe.

A5506 RT LT 50 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe.

L0984 Protective body sock, each.

L7520 Repair prosthetic device, labor component, per 15 minutes.

   The procedure codes that are being added to the fee schedule and that require prior authorization are set forth as follows:

Prior Authorization Requirements

   The following procedure codes and applicable modifiers that are being added to the fee schedule are for prostheses and orthoses and therefore require prior authorization under section 443.6(b)(1) of the Public Welfare Code (code) (62 P. S. § 443.6(b)(1)).

L1200 Thoracic-lumbar-sacral orthosis (TLSO), inclusive of furnishing initial orthosis only.

L1844 RT LT 50 Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated.

L1846 RT LT 50 KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, custom fabricated.

L1858 RT LT 50 KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated.

L2275 RT LT 50 Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined.

L2397 RT LT 50 Addition to lower extremity orthosis, suspension sleeve.

L2627 RT LT 50 Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables.

L2628 RT LT 50 Addition to lower extremity, pelvic control, metal, frame reciprocating hip joint and cables.

L3807 RT LT 50 Wrist-hand-finger orthosis (WHFO), without joint(s), prefabricated, includes fitting and adjustments, any type.

L4350 RT LT 50 Ankle control orthosis, stirrup style, rigid, includes any type interface (for example, pneumatic, gel), prefabricated, includes fitting and adjustment.

L5700 RT LT 50 Replacement, socket, below knee, molded to patient model.

L5701 RT LT 50 Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model.

L5704 RT LT 50 Custom shaped protective cover, below knee.

L5705 RT LT 50 Custom shaped protective cover, above knee.

L5706 RT LT 50 Custom shaped protective cover, knee disarticulation.

L5707 RT LT 50 Custom shaped protective cover, hip disarticulation.

L5972 RT LT 50 All lower extremity prostheses, flexible keel foot (safe, sten, bock dynamic or equal.

L5974 RT LT 50 All lower extremity prostheses, foot, single axis ankle/foot.

L5995 RT LT 50 Addition to lower extremity prosthesis, heavy duty feature (for patient weight less than 300 lbs).

   The following procedure codes and applicable modifiers that are being added to the fee schedule are for orthopedic shoes or other supportive devices for the feet by a physician for the purpose of correcting or otherwise treating abnormalities of the feet or legs and therefore require prior authorization under section 443.6(b)(6) of the code (62 P. S. § 443.6(b)(6)):

A5501 RT LT 50 For diabetics only, fitting (including follow-up) custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe.

A5510 RT LT 50 For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe.

A5511 RT LT 50 For diabetics only, custom-molded from model of patient's foot, multiple density insert(s), custom-fabricated, per shoe.

L3010 RT LT 50 Foot insert, removable, molded to patient model, longitudinal arch support, each.

L3340 RT LT 50 Heel wedge, sach.

L3350 RT LT 50 Heel wedge.

L3530 RT LT 50 Orthopedic shoe addition, sole, half.

L3540 RT LT 50 Orthopedic shoe addition, sole, full.

Fiscal Impact

   This change is anticipated to have minimal fiscal impact.

Public Comment

   Interested persons are invited to submit written comments regarding this notice to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered for any subsequent revision of the notice.

   Persons with a disability who require an auxiliary aid or service may submit comments using the AT&T Relay Services at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).

ESTELLE B. RICHMAN,
Secretary

   Fiscal Note: 14-NOT-460. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 05-2413. Filed for public inspection December 30, 2005, 9:00 a.m.]

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A5500	RT LT 50	For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multidensity insert(s), per shoe.
A5503	RT LT 50	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe.
A5504	RT LT 50	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe.
A5505	RT LT 50	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe.
A5506	RT LT 50	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe.
L0984		Protective body sock, each.
L7520		Repair prosthetic device, labor component, per 15 minutes.

L1200		Thoracic-lumbar-sacral orthosis (TLSO), inclusive of furnishing initial orthosis only.
L1844	RT LT 50	Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated.
L1846	RT LT 50	KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, custom fabricated.
L1858	RT LT 50	KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated.
L2275	RT LT 50	Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined.
L2397	RT LT 50	Addition to lower extremity orthosis, suspension sleeve.
L2627	RT LT 50	Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables.
L2628	RT LT 50	Addition to lower extremity, pelvic control, metal, frame reciprocating hip joint and cables.
L3807	RT LT 50	Wrist-hand-finger orthosis (WHFO), without joint(s), prefabricated, includes fitting and adjustments, any type.
L4350	RT LT 50	Ankle control orthosis, stirrup style, rigid, includes any type interface (for example, pneumatic, gel), prefabricated, includes fitting and adjustment.
L5700	RT LT 50	Replacement, socket, below knee, molded to patient model.
L5701	RT LT 50	Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model.
L5704	RT LT 50	Custom shaped protective cover, below knee.
L5705	RT LT 50	Custom shaped protective cover, above knee.
L5706	RT LT 50	Custom shaped protective cover, knee disarticulation.
L5707	RT LT 50	Custom shaped protective cover, hip disarticulation.
L5972	RT LT 50	All lower extremity prostheses, flexible keel foot (safe, sten, bock dynamic or equal.
L5974	RT LT 50	All lower extremity prostheses, foot, single axis ankle/foot.
L5995	RT LT 50	Addition to lower extremity prosthesis, heavy duty feature (for patient weight less than 300 lbs).

A5501	RT LT 50	For diabetics only, fitting (including follow-up) custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe.
A5510	RT LT 50	For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe.
A5511	RT LT 50	For diabetics only, custom-molded from model of patient's foot, multiple density insert(s), custom-fabricated, per shoe.
L3010	RT LT 50	Foot insert, removable, molded to patient model, longitudinal arch support, each.
L3340	RT LT 50	Heel wedge, sach.
L3350	RT LT 50	Heel wedge.
L3530	RT LT 50	Orthopedic shoe addition, sole, half.
L3540	RT LT 50	Orthopedic shoe addition, sole, full.