NOTICES
DEPARTMENT OF HUMAN SERVICES
Medical Assistance Program Fee Schedule Revisions; 2023 Healthcare Common Procedure Coding System Updates; Fee Adjustments; Prior Authorization Requirements
[53 Pa.B. 5346]
[Saturday, August 26, 2023]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 5, 2023.
The Department is adding and end-dating procedure codes as a result of the 2023 updates published by the Centers for Medicare & Medicaid Services to the Healthcare Common Procedure Coding System (HCPCS). The Department is also adding other procedure codes and making changes to procedure codes currently on the MA Program Fee Schedule, to include setting limitations and making fee adjustments. As follows, some of the procedure codes being added to the MA Program Fee Schedule will require prior authorization.
Procedure Codes Being Added or End-dated
The Department is adding the following procedure codes, and procedure code and modifier combinations to the MA Program Fee Schedule as a result of the 2023 HCPCS updates. These procedure codes may include the modifiers 80 (assistant surgeon), SG (ASC/SPU facility support component), TC (technical component), 26 (professional component), NU (purchase) or RR (rental).
Procedure Codes and Modifiers
15778 15778 (80) 30469 30469 (SG) 49591 49591 (SG) 49591 (80) 49592 49592 (SG) 49592 (80) 49593 49593 (SG) 49593 (80) 49594 49594 (SG) 49594 (80) 49595 49595 (SG) 49595 (80) 49596 49596 (80) 49613 49613 (SG) 49613 (80) 49614 49614 (SG) 49614 (80) 49615 49615 (SG) 49615 (80) 49616 49616 (80) 49617 49617 (80) 49618 49618 (80) 49621 49621 (80) 49622 49622 (80) 49623 49623 (80) 55867 55867 (80) 76883 76883 (TC) 76883 (26) 81449 81456 84433 87467 87468 87469 87478 87484 93569 93573 93574 93575 A4239 D0372 D0373 D0374 D7509 D7509 (SG) D9953 E0183 (NU) E0183 (RR) E2103 (NU) E2103 (RR) The Department is adding the following procedure codes, and procedure code and modifier combinations to the MA Program Fee Schedule based upon clinical review or provider request. These procedure codes may include modifiers FP (family planning) SG, 26, TC, RR or NU.
Procedure Codes and Modifiers
55874 55874 (SG) 81445 81450 81455 87563 87563 (FP) 92136 92136 (TC) 92136 (26) 99473 A4238 A4453 A4459 A4663 A4670 D4342 D4342 (SG) E0766 (RR) E2102 (NU) E2102 (RR) K0455 (NU) K0455 (RR) 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
49560 49561 49565 49566 49568 49570 49572 49580 49582 49585 49587 49590 49652 49653 49654 49655 49656 49657 99217 99218 99219 99220 99224 99225 99226 99241 99251 99318 99324 99325 99326 99327 99328 99334 99335 99336 99337 99343 K0553 K0554 Prior Authorization Requirements
The following procedure codes being added to the MA Program Fee Schedule will 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
84433 A4453 A4459 The following dental procedure codes and modifier combinations being added to the MA Program Fee Schedule will require prior authorization, under section 443.6(b)(5) of the code:
Procedure Codes
D4342 D4342 (SG) The following durable medical equipment (DME) procedure code and modifier combinations being added to the MA Program Fee Schedule will require prior authorization. Procedure codes with the NU modifier require prior authorization for purchase, under section 443.6(b)(2) of the code and 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
E0183 (NU) E0183 (RR) K0455 (NU) K0455 (RR) The Department will require prior authorization for procedure code and modifier combination E0766 (RR) being added to the MA Program Fee Schedule with the first month's rental, as authorized under section 443.6(b)(3) of the code.
Updates to Procedure Codes Currently on the MA Program Fee Schedule
Physicians' Services
The Department is updating the unit and service limitations to the following evaluation and management (E&M) procedure code as a result of clinical review and National Correct Coding Initiative edits as indicated as follows:
Procedure Code Present Unit Limit New Unit Limit Present Limit New Limit 99292 1:46 1:8 46 per day 8 per day Application of Topical Fluoride Varnish
The Department is updating the service limitation for procedure code 99188, for the application of topical fluoride varnish, from ''4 per calendar year'' to ''6 per calendar year'' as a result of clinical review.
Laboratory Services
The Department is adjusting the MA Program fee for the following laboratory procedure code as 55 Pa. Code § 1150.62(a) (relating to payment levels and notice of rate setting changes) requires that no MA fee exceed the Medicare Upper Payment Limit.
Procedure Code Description Current Fee New Fee 81243 FMR1 (fragile X mental retardation 1) (for example, fragile X mental retardation) gene analysis; evaluation to detect abnormal (for example, expanded) alleles $93.14 $45.63 DME and Medical Supplies
The Department is updating units and service limitations to the following medical supply procedure codes as a result of clinical review:
Procedure Code Present Unit Limit New Unit Limit Present Service Limit New Service Limit A4224 1:1 1:5 Once per week 5 per calendar month A4351 1:30 1:200 30 per 30 days Any combination of A4351, A4352, A4353; 200 Intermittent Catheter per calendar month A4352 1:30 1:200 30 per 30 days A4353 1:30 1:200 30 per 30 days The Department is adjusting the MA Program fees as identified as follows for the following medical supply procedure codes based on clinical review and provider request:
Procedure Code Description Current Fee New Fee A4224 Supplies for maintenance of insulin infusion catheter, per week $18.12 $21.58 A4351 Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer or hydrophilic, and the like), each $1.73 $1.83 A4352 Intermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric or hydrophilic, and the like), each $1.99 $6.83 A4353 Intermittent urinary catheter, with insertion supplies $5.40 $7.44 A4362 Skin barrier; solid, 4 x 4 or equivalent; each $0.56 $3.70 The Department is end-dating the U7 pricing modifier for medical supply procedure code A4353 as there is only one fee for this procedure code, so the pricing modifier is no longer necessary.
Dental Services
The Department will no longer require procedure codes D1310 and D1330 be billed together as a result of clinical review. Each procedure can now be billed separately.
The Department is updating the service limitation to include a lifetime limit for the following dental procedure code as a result of clinical review:
Procedure Code Present Limit New Limit D1354 1 per tooth per day, maximum of 10 teeth per day, 4 times per tooth per year 1 per tooth per day, maximum of 10 teeth per day, 4 times per tooth per year, 6 times per tooth per lifetime The Department is end-dating the following PT/Spec/Place of Service (POS) combinations, as indicated as follows, from dental procedure code D1354 with and without the SG modifier as these settings were determined to be clinically inappropriate for this service:
Procedure Code End-dated PT/Spec/POS D1354 (SG) 01 (Inpatient Hospital)/021 (Short Procedure Unit)/24 (Ambulatory Surgical Center) 02 (Ambulatory Surgical Center)/020 (Ambulatory Surgical Center)/24 D1354 27 (Dentist)/All/21 (Inpatient Hospital) 27/All/24 The Department is updating the unit limitation to the following dental procedure code as a result of clinical review:
Procedure Code Present Unit Limit New Unit Limit D4341 1:4 1:2 The Department is updating the service limitations to the following dental procedure codes as a result of clinical review:
Procedure Code Present Limit New Limit D1110 Any combination of D1110, D1120, D4346, D4910, for routine prophylaxis and periodontal maintenance, totaling 3 per year. 1 per 180 days D1120 1 per 180 days D4346 1 per 180 days D4910 1 per 90 days Telehealth—All Provider Types
The Department is adding POS 10, (Telehealth Provided in a Patient's Home) for the following procedure codes and procedure code and modifier combinations for all PT/Spec combinations as the Department determined this setting is appropriate for the performance of these services. These procedure codes may include modifiers FP, GN (speech pathology), HD (pregnant/parenting women's program), HQ (group therapy), TC, TJ (Childhood Nutrition Weight Management Services), TM (School-Based ACCESS Program), UA (audiology), UB (pricing), U3 (pricing), U4 (pricing), U5 (pricing), U6 (pricing), U7, U8 (pricing), U9 (pricing), 24 (unrelated E&M service by the same physician or other qualified health care professional during a postoperative period), 25 (significant, separate identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service), 26, 27 (multiple outpatient hospital E&M encounters on the same date), 57 (decision for surgery).
Procedure Codes with the Addition of POS 10
77427 90791 (U3) (TM) 90791 (U4) (TM) 90832 (U3) (TM) 90853 (U3) (TM) 92002 92002 (24) 92002 (25) 92002 (27) 92002 (57) 92004 92004 (24) 92004 (25) 92004 (27) 92004 (57) 92012 92012 (24) 92012 (25) 92012 (27) 92012 (57) 92014 92014 (24) 92014 (25) 92014 (27) 92014 (57) 92507 92507 (U3) (TM) 92507 (U4) (TM) (UA) 92507 (U9) (TM) (HQ) 92507 (UB) (TM) (GN) 92508 92508 (U3) (TM) 92521 (U9) 92522 (U9) 92523 (U9) 92523 (U3) (TM) 92523 (U4) (TM) (GN) 92523 (U5) (TM) 92523 (U6) (TM) 92524 (U9) 92526 92550 92552 92553 92555 92556 92557 92563 92565 92567 92568 92570 92587 92587 (TC) 92587 (26) 92588 92588 (TC) 92588 (26) 92601 92602 92603 92604 92610 92625 92625 (52) 92626 92627 94002 94003 94004 (U7) 94664 95970 95971 95972 95983 95984 96040 96040 (24) 96040 (25) 90640 (27) 96040 (57) 96105 96105 (TC) 96105 (26) 96110 96112 96113 96125 96127 96130 96131 96132 96133 96136 96137 96156 (TJ) 96156 (U5) (TJ) 96156 (U3) (TM) 96156 (U4) (TM) 96158 (U3) (TJ) 96159 (U3) (TJ) 96160 96160 (FP) 96161 96164 (TJ) 96165 (TJ) 96167 (TJ) 96168 (TJ) 97110 97110 (U3) (TM) 97110 (U8) (TM) (HQ) 97112 97116 97129 97130 97161 (U8) 97162 (U8) 97162 (U3) (TM) 97163 (U8) 97164 (U8) 97164 (U3) (TM) 97165 (U8) 97166 (U8) 97166 (U3) (TM) 97167 (U8) 97168 (U8) 97168 (U3) (TM) 97530 97530 (U7) 97530 (U3) (TM) 97530 (U8) (TM) (HQ) 97550 97755 99188 G0108 G0109 G9016 (HD) H0004 (U8) (HD) H0004 (U9) (HD) H0031 (U3) (TM) H0031 (U4) (TM) H0046 (U3) (TM) H0046 (U7) (TM) H0046 (U7) (TM) (HQ) H1002 (HD) H2027 (TM) (HQ) H2027 (U3) (TM) S9152 S9152 (U3) (TM) S9152 (U4) (TM) S9436 (HD) S9437 (HD) S9444 (HD) S9451 (HD) S9470 (U3) (TJ) S9470 (U7) (HD) T1023 T1023 (U3) (TM) D0140 D1206 D1310 D1320 D1330 The Department is end-dating the POS 02 (Telehealth Provided Other than in a Patient's Home) for all provider types for the following procedure codes and procedure code and modifier combinations as the Department determined that telehealth is not appropriate for these services. These procedure codes may include modifiers TC, TM, U1 (pricing), U3, U7, 22 (increased procedural services), 52 (incomplete EPSDT screen), 26.
Procedure Codes
90993 (U7) 90993 (U7) (22) 92630 92633 93224 93226 93227 93228 93268 93270 93271 93272 93278 93278 (TC) 93278 (26) 93292 93292 (TC) 93292 (26) 93293 93293 (TC) 93293 (26) 93294 93295 93296 93297 93298 93724 93724 (TC) 93724 (26) 93750 94010 94010 (TC) 94010 (26) 94060 94060 (TC) 94060 (26) 94150 94150 (TC) 94150 (26) 94200 94200 (TC) 94200 (26) 94375 94375 (TC) 94375 (26) 94642 94644 94645 94660 94662 94680 94680 (TC) 94680 (26) 94681 94681 (TC) 94681 (26) 94690 94690 (TC) 94690 (26) 94726 94726 (TC) 94726 (26) 94727 94727 (TC) 94727 (26) 94728 94728 (TC) 94728 (26) 94729 94729 (TC) 94729 (26) 94760 94761 94772 94777 95004 95017 95018 95024 95027 95028 95044 95070 95076 95079 95115 95117 95165 95180 95250 95251 95782 95782 (TC) 95782 (26) 95783 95783 (TC) 95783 (26) 95805 95805 (TC) 95805 (26) 95807 95807 (TC) 95807 (26) 95808 95808 (TC) 95808 (26) 95810 95810 (TC) 95810 (26) 95811 95811 (TC) 95811 (26) 95812 95812 (TC) 95812 (26) 95813 95813 (TC) 95813 (26) 95816 95816 (TC) 95816 (26) 95819 95819 (TC) 95819 (26) 95822 96110 (U1) 96161 (52) 97533 (U3) (TM) 99172 (U3) (TM) 99172 (U4) (TM) 99173 99490 99491 99499 G2066 S0618 T1002 (U3) (TM) The Department is end-dating the GT (telemedicine) modifier for the following procedure codes, as a result of the addition of POS 02 and POS 10 to procedure codes that the Department has determined are appropriate for delivery by telehealth:
Procedure Codes
90791 90832 90853 92521 92522 92523 92524 97161 97162 97163 97164 97165 97166 97167 97168 S9152 Fiscal Impact
The estimated cost for Fiscal Year 2023-2024 is $1.815 million ($0.824 million in State funds and $0.991 million in Federal funds). The estimated annualized cost is $2.177 million ($0.989 million in State funds and $1.188 million in Federal 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-PWMAProgComments@ 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 (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
VALERIE A. ARKOOSH,
SecretaryFiscal Note: 14-NOT-1588. Under section 612 of The Administrative Code of 1929 (71 P.S. § 232), (1) General Fund; (2) Implementing Year 2023-24 is $824,000; (3) 1st Succeeding Year 2024-25 through 5th Succeeding Year 2028-29 are $989,000; (4) 2022-23 Program—$746,852,000; 2021-22 Program—$644,059,000; 2020-21 Program—$808,350,000; (7) MA—Fee-for-Service; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 23-1155. Filed for public inspection August 25, 2023, 9:00 a.m.]
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