2470 Medical Assistance Program fee schedule revisions; 2010 HCPCS updates; prior authorization requirements?
DEPARTMENT OF PUBLIC WELFARE Medical Assistance Program Fee Schedule Revisions; 2010 HCPCS Updates; Prior Authorization Requirements [40 Pa.B. 7438]
[Saturday, December 25, 2010]The Department of Public Welfare (Department) announces changes to the Medical Assistance (MA) Program Fee Schedule and prior authorization requirements. These changes are effective for dates of service on and after January 3, 2011.
Fee Schedule Revisions
The Department is adding and end-dating procedure codes as a result of implementing the 2010 updates made by the Centers for Medicare and Medicaid Services (CMS) to the Healthcare Common Procedure Coding System (HCPCS). The Department is also end-dating other procedure codes, and procedure code and modifier combinations, including some codes previously end-dated by CMS. Additionally, the Department is adding procedure codes, and procedure code and modifier combinations, to the MA Program Fee Schedule as a result of significant program exception requests. Finally, some of the procedure codes being added to the MA Program Fee Schedule will require prior authorization.
Fees for the new procedure codes will be published in a Medical Assistance Bulletin that will be issued to all providers.
The following procedure codes are being added to the MA Program Fee Schedule as a result of the 2010 HCPCS updates:
Procedure Codes
and ModifiersProcedure Codes
and ModifiersProcedure Codes
and ModifiersProcedure Codes
and ModifiersProcedure Codes
and Modifiers14301 14301 (80) 14301 (SG) 14302 14302 (80) 21011 21012 21012 (SG) 21013 21013 (80) 21013 (SG) 21014 21014 (80) 21014 (SG) 21016 21016 (80) 21016 (SG) 21552 21552 (SG) 21554 21554 (SG) 21558 21558 (80) 21558 (SG) 21931 21931 (SG) 21932 21932 (SG) 21933 21933 (SG) 21936 21936 (SG) 22901 22901 (80) 22901 (SG) 22902 22902 (SG) 22903 22903 (SG) 22904 22904 (80) 22904 (SG) 22905 22905 (80) 22905 (SG) 23071 23071 (SG) 23073 23073 (SG) 23078 23078 (80) 23078 (SG) 24071 24071 (SG) 24073 24073 (SG) 24079 24079 (SG) 25071 25071 (SG) 25073 25073 (SG) 25078 25078 (80) 25078 (SG) 26111 26111 (SG) 26113 26113 (SG) 26118 26118 (SG) 27043 27043 (SG) 27045 27045 (80) 27045 (SG) 27059 27059 (80) 27059 (SG) 27337 27337 (SG) 27339 27339 (SG) 27364 27364 (80) 27364 (SG) 27616 27616 (80) 27616 (SG) 27632 27632 (SG) 27634 27634 (SG) 28039 28041 28041 (SG) 28047 28047 (SG) 29581 31626 31626 (SG) 32552 32552 (SG) 32553 32553 (SG) 32561 32562 33782 33782 (80) 33783 33783 (80) 33981 33981 (80) 33982 33982 (80) 33983 33983 (80) 36147 36147 (SG) 36148 37761 37761 (SG) 43281 43281 (80) 43282 43282 (80) 43775 43775 (80) 45171 45171 (80) 45171 (SG) 45172 45172 (80) 45172 (SG) 46707 46707 (SG) 49411 49411 (SG) 51727 51727 (TC) 51727 (26) 51728 51728 (TC) 51728 (26) 51729 51729 (TC) 51729 (26) 57426 57426 (80) 57426 (SG) 63661 63661 (80) 63661 (SG) 63662 63662 (80) 63662 (SG) 63663 63663 (80) 63663 (SG) 63664 63664 (80) 63664 (SG) 64490 64490 (SG) 64491 64492 64493 64493 (SG) 64494 64495 75571 75571 (TC) 75571 (26) 75572 75572 (TC) 75572 (26) 75573 75573 (TC) 75573 (26) 75574 75574 (TC) 75574 (26) 75791 75791 (TC) 75791 (26) 78451 78451 (TC) 78451 (26) 78452 78452 (TC) 78452 (26) 78453 78453 (TC) 78453 (26) 78454 78454 (TC) 78454 (26) 83987 84145 84431 86305 86352 86780 86780 (FP) 86825 86826 87150 87153 87493 88387 88387 (TC) 88387 (26) 88388 88388 (TC) 88388 (26) 92540 92540 (TC) 92540 (26) 92550 92570 93750 95905 95905 (TC) 95905 (26) A4264 A4456 E0433 (RR) G0430 G0431 K0739 L8031 L8032 L8627 L8628 L8629 The following procedure codes are being added to the MA Program Fee Schedule as a result of significant program exception requests:
Procedure Codes
and ModifiersProcedure Codes
and ModifiersProcedure Codes
and ModifiersProcedure Codes
and ModifiersProcedure Codes
and Modifiers20690 20690 (SG) 36475 36475 (SG) 36476 36478 36478 (SG) 36479 37722 37722 (SG) 49061 49061 (SG) 61533 61533 (80) 92526 93290 93290 (TC) 93290 (26) 93291 93291 (TC) 93291 (26) 93297 93298 93299 99464 G0328 The following procedure codes are being end-dated from the MA Program Fee Schedule either as a result of the 2010 HCPCS updates or because they were previously end-dated by CMS:
Procedure Codes
01632 14300 23221 23222 24151 24153 26255 26261 27079 29220 36145 36834 45170 46210 46211 46937 46938 51795 63660 64470 64472 64475 64476 75790 78460 78461 78464 78465 78478 78480 82307 86781 90185 90379 92569 A4365 A6200 A6201 A6202 A6543 E1340 E2223 E2393 G0392 G0393 K0157 L0210 L0332 L1800 L1815 L1825 L1901 L2770 L3651 L3652 L3700 L3701 L3909 L3911 L6639 The Department is end-dating the following procedure code from the MA Program Fee Schedule because it is a service related to infertility treatment. Section 443.6(f) of the Public Welfare Code (code) (62 P. S. § 443.6), regarding reimbursement for certain medical assistance items and services), prohibits the Department from paying a provider for any medical services, procedures or drugs related to infertility therapy:
Procedure Code Procedure Description 58760 Fimbrioplasty The Department is end-dating the rental modifier for the following procedure code based on the United States Food and Drug Administration recommendation that a breast pump should only be used by one woman. The Department is opening the purchase modifier (NU) for the following procedure code:
Procedure Code Procedure Description E0603 Breast pump, electric (AC and/or DC), any type Fee Adjustment
The Department is increasing the MA Program fee for the following procedure code when billed with modifier SG:
Procedure Code Description Current Fee MA Fee Effective January 3, 2011 66982 (SG) Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (for example, irrigation and aspiration or phacoemulsification), complex, requiring devices or
techniques not generally used in routine cataract surgery (for example, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage.$776.00 $1,654.00 Prior Authorization Requirements
The following procedure codes that are being added to the MA Program Fee Schedule are prostheses and orthoses that require 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) (Act 42):
Procedure Code Procedure Description L8031 Breast prosthesis, silicone or equal, with integral adhesive L8032 Nipple prosthesis, reusable, any type, each L8627 Cochlear implant, external speech processor, component, replacement L8628 Cochlear implant, external controller component, replacement L8629 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement The following procedure code being added to the MA Program Fee Schedule is durable medical equipment (DME) and will require prior authorization, as authorized under section 443.6(b)(2) of the code, as amended by Act 42:
Procedure Code Procedure Description E0603 (NU) Breast pump, electric (AC and/or DC), any type The following procedure codes being added to the MA Program Fee Schedule will require prior authorization, as authorized under section 443.6(b)(7) of the code, as amended by Act 42:
Procedure Code Procedure Description 75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium 75572 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed 75573 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed) 75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) 78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) 78452 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest or stress (exercise or pharmacologic) and/or rest reinjection 78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study at rest or stress (exercise or pharmacologic) 78454 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection A4264 Permanent implantable contraceptive intratubal occlusion device(s) and delivery system Fiscal Impact
The estimated cost for Fiscal Year (FY) 2010-2011 is $1.512 million ($0.563 million in State funds). The annualized cost for FY 2011-2012 is $3.628 million ($1.680 million in State funds). These State fund estimates are based on the increased Federal Medical Assistance Percentages as determined under the American Recovery and Reinvestment Act of 2009.
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 Deputy Secretary's Office, Attention: Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received 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 AT&T Relay Service (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
MICHAEL P. NARDONE,
Acting SecretaryFiscal Note: 14-NOT-675. (1) General Fund; (2) Implementing Year 2010-11 is $563,000; (3) 1st Succeeding Year 2011-12 is $1,680,000; 2nd Succeeding Year 2012-13 is $1,685,000; 3rd Succeeding Year 2013-14 is $1,685,000; 4th Succeeding Year 2014-15 is $1,685,000; 5th Succeeding Year 2015-16 is $1,685,000; (4) 2009-10 Program—$435,939,000; 2008-09 Program—$555,085,000; 2007-08 Program—$593,922,000; (7) MA—Outpatient; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 10-2470. Filed for public inspection December 23, 2010, 9:00 a.m.]
