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PA Bulletin, Doc. No. 05-2279

NOTICES

DEPARTMENT OF
PUBLIC WELFARE

Medical Assistance Program Fee Schedule Procedure Code Changes for Durable Medical Equipment, Medical Supplies, Vision Supplies and Hearing Supplies; Prior Authorization Requirements

[35 Pa.B. 6707]

   The Department of Public Welfare (Department) announces several changes to the Medical Assistance (MA) Program Fee Schedule for procedure codes for durable medical equipment, medical supplies, vision supplies and hearing supplies and the accompanying prior authorization requirements.

Fee Schedule Revisions

   The Department is end-dating the following local procedure codes for durable medical equipment and medical supplies. Those local procedure codes will not be compensable for services provided after December 11, 2005.

Local Procedure Code Local Procedure Code Local Procedure Code Local Procedure Code
W0202 Y9939 Z1351 Z4452
W1765 Y9953 Z1400 Z4454
W4405 Y9957 Z1401 Z4455
W4406 Y9958 Z1402 Z4456
W4407 Y9959 Z1403 Z4457
W4408 Y9964 Z1404 Z4458
W4409 Y9965 Z1406 Z4459
W4410 Y9966 Z1408 Z4491
W8697 Y9970 Z1826 Z4511
W9884 Z0043 Z2161 Z4553
Y0012 Z0053 Z2162 Z4561
Y0017 Z0241 Z2163 Z4562
Y0034 Z0242 Z3062 Z4600
Y2021 Z0243 Z3064 Z4611
Y5241 Z0244 Z3091 Z4612
Y5242 Z0246 Z3092 Z4613
Y5298 Z0247 Z3255 Z4615
Y8938 Z0248 Z3257 Z4616
Y9400 Z0249 Z3731 Z4617
Y9401 Z0250 Z4140 Z4618
Y9640 Z0281 Z4141 Z4619
Y9641 Z0334 Z4210 Z4620
Y9642 Z0460 Z4211 Z4621
Y9651 Z0461 Z4217 Z4622
Y9652 Z0521 Z4219 Z4623
Y9655 Z0522 Z4251 Z4624
Y9656 Z0523 Z4252 Z4625
Y9657 Z0524 Z4253 Z4626
Y9658 Z0527 Z4256 Z4637
Y9659 Z0530 Z4262 Z4650
Y9660 Z0531 Z4264 Z4651
Y9661 Z0532 Z4266 Z4652
Y9662 Z0533 Z4297 Z7501
Y9666 Z0534 Z4330 Z7511
Y9667 Z0536 Z4338 Z8907
Y9668 Z0555 Z4340 Z9002
Y9669 Z0600 Z4342 Z9003
Y9670 Z0625 Z4348 Z9005
Y9894 Z0935 Z4354 Z9006
Y9895 Z0936 Z4355 Z9007
Y9924 Z0950 Z4356 Z9008
Y9926 Z0977 Z4373 Z9010
Y9928 Z0980 Z4374 Z9800
Y9929 Z0981 Z4376 Z9801
Y9930 Z1091 Z4378 Z9805
Y9932 Z1092 Z4379 Z9806
Y9933 Z1093 Z4382 Z9809
Y9934 Z1094 Z4384 Z9810
Y9935 Z1095 Z4403 Z9811
Y9938 Z1096 Z4451 Z9814

   Except as set forth as follows, these local codes are being cross walked to either existing National codes or new National procedure codes that are being added to the MA Program Fee Schedule.

   Local procedure code Z9800 is being end-dated and not cross walked to a National procedure code. Pharmacy providers can bill for this item from the Drug Reference File.

   Local procedure code Y9661 is being cross walked to National procedure code E0935. National procedure code E0935 can only be used for the rental of the passive motion exercise device. Therefore, effective with dates of service December 12, 2005, the Department will only allow for the rental, not the purchase, of this durable medical equipment item.

   Local procedure code W0202 is being cross walked to National procedure code E0445. The local procedure code only allowed for the rental of the pulse oximeter. With advances in medical technology, the purchase price for a pulse oximeter has decreased over the years since the local procedure code was added to the MA Program Fee Schedule, making it more cost effective for the Department to pay for the purchase of a pulse oximeter rather than paying for continuous rental. For this reason, the Department is adding a purchase fee for E0445 to the MA Program Fee Schedule and reducing the fee for rental.

   Effective with dates of service December 12, 2005, the Department is adding the following new National procedure codes and modifiers to the MA Program Fee Schedule.

National Procedure    Code  Pricing Modifier Informational      Modifier   MA Fee
A4206 $    0.29
A4207 $    0.29
A4208 $    0.29
A4209 $    0.29
A4213 $    0.29
A4213 U8 $    0.88
A4215 $    0.18
A4221 $  18.12
A4222 $  28.00
A4335 U8 $    0.75
A4335 $    0.10
A4335 U7 $    0.50
A4353 U7 $    5.40
A4362 $    0.56
A4365 $    1.50
A4402 $    0.90
A4421 $    1.20
A4554 $    0.19
A4580 $  28.00
A4580 U7 $  39.00
A4580 U8 $  55.00
A4606 $  30.00
A4606 U7 $  80.00
A4617 $    2.40
A4618 NU $  98.00
A4627 $  18.00
A4628 $    4.00
A4629 $    3.00
A4927 $    8.00
A6208 $    9.24
A6501 $150.00
A6503 $  53.00
A6504 RT, LT, 50 $  71.00
A6505 RT, LT, 50 $  22.00
A6506 RT, LT, 50 $  71.00
A6509 $  83.00
A6511 $107.50
A6512 U9 $  80.00
A6512 U7 $  24.50
A6512 U8 $  36.50
A6512 $    7.50
A9900 $    8.15
B4164 $  67.00
B4168 $  67.00
B4172 $  67.00
B4176 $  67.00
B4178 $  67.00
B4180 $  67.00
B4184 $  67.00
B4186 $  67.00
B4189 $  67.00
B4193 $  67.00
B4197 $  67.00
B4199 $  67.00
B4216 $  67.00
B5000 $  67.00
B5100 $  67.00
B5200 $  67.00
B9998 U8 $  90.84
E0144 RR $  16.24
E0144 NU $162.40
E0241 U7 $  16.50
E0241 U9 $  21.00
E0241 NU $  15.50
E0241 U8 $  17.00
E0241 U4 $  18.00
E0315 NU $  17.00
E0445 RR $  35.00
E0445 NU $395.00
E0602 $  25.00
E0710 $  15.50
E1035 NU $579.00
E1060 NU $770.00
E1060 RR $  65.00
E1223 NU $505.00
E1223 RR $  45.00
E1224 NU $580.00
E1224 RR $  56.00
E1228 NU $129.00
E1231 NU $670.00
E1340 $    6.25
E1399 U8 $  49.00
E1399 U7 $  20.00
E1800 NU RT, LT, 50 $695.00
K0009 NU $780.00
K0014 NU $780.00
K0014 U7 $925.00
K0108 U8 $167.00
K0108 UB $  70.00
K0108 U9 $200.00
K0108 NU $250.00
K0108 U7 $160.00
L1200 $790.00
L3060 RT, LT, 50 $  55.00
L3201 RT, LT, 50 $  19.50
L3202 RT, LT, 50 $  19.50
L3203 RT, LT, 50 $  19.50
L3204 RT, LT, 50 $  19.50
L3206 RT, LT, 50 $  19.50
L3207 RT, LT, 50 $  19.50
L3215 $  39.00
L3216 $  39.00
L3217 $  39.00
L3219 $  39.00
L3221 $  39.00
L3222 $  39.00
L3224 RT, LT, 50 $  19.50
L3225 RT, LT, 50 $  19.50
L3230 $  39.00
L3250 RT, LT, 50 $  19.50
L7520 $    7.50
L8190 $  53.50
L8200 $  53.50
L8210 RT, LT, 50 $  79.00
L8500 $225.00
L8501 $  75.00
S8189 U7 $    6.00
S8189 U8 $  14.00
S8424 RT, LT, 50 $  24.50
S8428 RT, LT, 50 $    6.00
S8490 $    0.19
S8999 $  40.00
S8999 NU $225.00
V2521 VP, RT, LT, 50 $  90.00
V2522 VP, RT, LT, 50 $  90.00
V2523 VP, RT, LT, 50 $  90.00
V5014 $  45.00
V5160 $225.00
V5265 $  15.00
V5266 $    1.25

   Medical Assistance Bulletins will be issued to providers of durable medical equipment, medical supplies, vision supplies and hearing supplies that include a cross walk of all the local procedure codes that are being end-dated, the National procedure codes and modifiers, as applicable, that are replacing them and any specific prior authorization requirements.

Prior Authorization Requirements

   As set forth as follows, the following National procedure codes require prior authorization for dates of service on or after December 12, 2005. In some instances, and as noted as follows, these prior authorization requirements are for items, services or procedures that did not previously require prior authorization.

   In some instances durable medical equipment, medical supplies, vision supplies and hearing supplies did not previously require prior authorization. Section 443.6(a) of the Public Welfare Code (code) (62 P. S. § 443.6(a)), regarding reimbursement for certain medical assistance items and services, sets forth that in order to receive payment for items or services in subsection (b), the provider must secure authorization prior to actually providing the items or services. As noted as follows, effective for dates of service on or after December 12, 2005, the National procedure code requires prior authorization.

   The following National procedure codes are for prostheses and orthoses and are therefore subject to prior authorization under section 443.6(b)(1) of the code as amended by the act of July 7, 2005 (P. L. 177 No. 42):

L0100  Cranial orthosis (helmet), with or without soft interface, molded to patient model.
Note: This National procedure code did not previously require prior authorization.

L0110  Cranial orthosis (helmet), with or without soft-interface, nonmolded.
Note: This National procedure code did not previously require prior authorization.

L0976  LSO, full corset.
Note: This National procedure code did not previously require prior authorization.

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

L1810  RT, LT, 50 Knee orthosis, elastic with joints, prefabricated, includes fitting and adjustment.
Note: This National procedure code did not previously require prior authorization.

L8190  Gradient compression stocking, waist length, 18-30 mmhg, each.

L8195  Gradient compression stocking, waist length, 30-40 mmhg, each.
Note: This National procedure code did not previously require prior authorization.

L8200  Gradient compression stocking, waist length, 40-50 mmhg, each.

L8210  RT, LT, 50 Gradient compression stocking, custom made.

L8500  Artificial larynx, any type.
Note: The local code that L8500 is replacing did not require prior authorization. The National procedure code L8500 requires prior authorization.

L8501  Tracheostomy speaking valve.

V5242  RT, LT, 50 Hearing aid, analog, monaural hearing aid, CIC (completely in the ear canal).
Note: The local procedure code that V5242 is replacing did not require prior authorization. The National procedure code V5242 requires prior authorization.

V5243  RT, LT, 50 Hearing aid, analog, monaural hearing aid, ITC (in the canal).
Note: The local procedure code that V5243 is replacing did not require prior authorization. The National procedure code V5243 requires prior authorization.

V5248  Hearing aid, analog, binaural, CIC (completely in the ear canal).
Note: The local procedure code that V5248 is replacing did not require prior authorization. The National procedure code V5248 requires prior authorization.

V5249  Hearing aid, analog, binaural, ITC (in the canal).
Note: The local procedure code that V5249 is replacing did not require prior authorization. The National procedure code V5249 requires prior authorization.

   The following National procedure codes for appliances or equipment require prior authorization under section 443.6(b)(2) of the code either because the item costs more than $600 or because the item costs $600 or less and the Department has determined to require prior authorization:

E0144  NU Walker, enclosed, 4 sided frame, rigid or folding wheeled, with posterior seat.

E1035  NU Multi-positional patient transfer system with integrated seat operated by caregiver.

E1060  NU Fully reclining wheelchair; detachable arms, desk or full length, swingaway detachable, elevating legrests.

E1223  NU Wheelchair with detachable arms and foot rests.

E1224  NU Wheelchair with detachable arms, elevating leg rests.

E1228  NU Special back height for wheelchair.

E1231  NU Wheelchair, pediatric size, tilt-n-space, rigid, adjustable with seating system.

E1250  NU Lightweight wheelchair; fixed full-length arms, swingaway detachable footrests.
Note: This National procedure code did not previously require prior authorization.

E1270  NU Lightweight wheelchair; fixed full-length arms, swingaway detachable, elevating legrests.
Note: This National procedure code did not previously require prior authorization.

E1298  NU Special wheelchair seat depth and/or width, by construction.
Note: This National procedure code did not previously require prior authorization.

E1800  NU Dynamic adjustable elbow extension/flexion device, includes soft interface material.

K0009  NU Other manual wheelchair/base.

K0014  NU Other motorized power wheelchair base.

K0108  NU Wheelchair component or accessory, not otherwise specified.

   The following National procedure codes are for oxygen and related equipment and are subject to prior authorization, as set forth in section 443.6(b)(4) of the code:

E0424  RR Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask and tubing.
Note: This National procedure code did not previously require prior authorization.

E0439  RR Stationary liquid oxygen system, rental; includes container, contents, regulator, flow meter, humidifier, nebulizer, cannula or mask and tubing.
Note: This National procedure code did not previously require prior authorization.

E0445  NU Oximeter device for measuring blood oxygen levels noninvasively.

E1390  RR Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate.
Note: This National procedure code did not previously require prior authorization.

S8999  NU Resuscitation bag (for use by patient on artificial respiration during power failure or other catastrophic event).

   The following National procedure codes are for orthopedic shoes or other supportive devices for the feet and are therefore subject to prior authorization under section 443.6(b)(6) of the code:

L3060  RT, LT, 50 Foot, arch support, removable, premolded, longitudinal/ metatarsal, each.

L3140  Foot, abduction rotation bar, including shoes.
Note: This National procedure code did not previously require prior authorization.

L3201  RT, LT, 50 Orthopedic shoe, oxford with supinator or pronator, infant.

L3202  RT, LT, 50 Orthopedic shoe, oxford with supinator or pronator, child.

L3203  RT, LT, 50 Orthopedic shoe, oxford with supinator or pronator, junior.

L3204  RT, LT, 50 Orthopedic shoe, hightop with supinator or pronator, infant.

L3206  RT, LT, 50 Orthopedic shoe, hightop with supinator or pronator, child.

L3207  RT, LT, 50 Orthopedic shoe, hightop with supinator or pronator, junior.

L3215  Orthopedic footwear, ladies shoes, oxford.

L3216  Orthopedic footwear, ladies shoes, depth inlay.

L3217  Orthopedic footwear, ladies shoes, hightop, depth inlay.

L3219  Orthopedic footwear, mens shoes, oxford.

L3221  Orthopedic footwear, mens shoes, depth inlay.

L3222  Orthopedic footwear, mens shoes, hightop, depth inlay.

L3224  RT, LT, 50 Orthopedic footwear, women's shoe, oxford, used as an integral part of a brace (orthosis).

L3225  RT, LT, 50 Orthopedic footwear, men's shoe, oxford, used as an integral part of a brace (orthosis).

L3230  Orthopedic footwear, custom shoes, depth inlay.

L3250  RT, LT, 50 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each.

   The following National procedure code is subject to prior authorization as authorized in section 443.6(b)(7) of the code:

V5160  Dispensing fee, bilateral.

   Services rendered on or after December 12, 2005, must be billed using the National procedure code and modifiers, if applicable.

Fiscal Impact

   The conversion from local to National procedure codes is anticipated to be budget neutral and, therefore, these changes will have no 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 revisions 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-453. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 05-2279. Filed for public inspection December 9, 2005, 9:00 a.m.]



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