251 Medical Assistance program fee schedule revisions; 2004 HCPCS updates; prior authorization requirements

DEPARTMENT OF
PUBLIC WELFARE

Medical Assistance Program Fee Schedule Revisions; 2004 HCPCS Updates; Prior Authorization Requirements

[35 Pa.B. 803]

   The Department of Public Welfare (Department) announces several changes to the Medical Assistance (MA) Program Fee Schedule and accompanying prior authorization requirements.

Fee Schedule Revisions

   The Department is adding and end dating procedure codes as a result of implementing the 2004 updates made by the Centers for Medicare and Medicaid Services to the Healthcare Common Procedure Coding System (HCPCS). The 2004 HCPCS codes are effective for dates of service on and after February 7, 2005.

   In addition to the HCPCS updates, the Department is adding procedure codes 35500, L8509 and P9017 with effective dates of service on and after February 7, 2005. Procedure codes 35500 and P9017 are being added due to significant Program Exception requests. Procedure code L8509 is being added due to the 2004 addition of procedure code L8511 which requires procedure code L8509 to be billed as a primary code.

   Fees for the added procedure codes will be published in a MA Bulletin that will be issued to all providers.

Prior Authorization Requirements

   The following new HCPCS procedure codes are for items of durable medical equipment that cost more than $100 and therefore are subject to prior authorization under section 443.6(b)(2) of the Public Welfare Code (code) (62 P. S. § 443.6(b)(2)) concerning reimbursement for certain MA items and services:

E0140	NU	Walker, with trunk support, adjustable or fixed height, any type
E0248	NU	Transfer bench, heavy duty, for tub or toilet with or without commode opening
E0562	NU	Humidifier, heated, used with positive airway pressure device
E0637	NU	Combination sit to stand system, any size, with seat lift feature, with or without wheels
E0638	NU	Standing frame system, any size, with or without wheels
E0955	NU	Wheelchair accessory, headrest, cushioned, prefabricated, including fixed mounting hardware, each
E0957	NU	Wheelchair accessory, medial thigh support, prefabricated, including fixed mounting hardware, each
E0983	NU	Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control
E0984	NU	Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control
E0985	NU	Wheelchair accessory, seat lift mechanism
E1002	NU	Wheelchair accessory, power seating system, tilt only
E1003	NU	Wheelchair accessory, power seating system, recline only, without shear reduction
E1004	NU	Wheelchair accessory, power seating system, recline only, with mechanical shear reduction
E1005	NU	Wheelchair accessory, power seating system, recline only, with power shear reduction
E1006	NU	Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction
E1007	NU	Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction
E1008	NU	Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction
E1010	NU	Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, each
E1028	NU	Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory
E1029	NU	Wheelchair accessory, ventilator tray, fixed
E1030	NU	Wheelchair accessory, ventilator tray, gimbaled
E2201	NU	Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches
E2202	NU	Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches
E2203	NU	Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches
E2204	NU	Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches
E2310	NU	Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch and fixed mounting hardware
E2311	NU	Power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch and fixed mounting hardware
E2320	NU	Power wheelchair accessory, hand or chin control interface, remote joystick or touchpad, proportional, including all related electronics and fixed mounting hardware
E2321	NU	Power wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch and fixed mounting hardware
E2322	NU	Power wheelchair accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch and fixed mounting hardware
E2325	NU	Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch and manual swingaway mounting hardware
E2326	NU	Power wheelchair accessory, breath tube kit for sip and puff interface
E2327	NU	Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch and fixed mounting hardware
E2328	NU	Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware
E2329	NU	Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array and fixed mounting hardware
E2330	NU	Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array and fixed mounting hardware
E2340	NU	Power wheelchair accessory, nonstandard seat frame width, 20-23 inches
E2341	NU	Power wheelchair accessory, nonstandard seat frame width, 24-27 inches
E2342	NU	Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches
E2343	NU	Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches
E2351	NU	Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface
E2361	NU	Power wheelchair accessory, 22nf sealed lead acid battery, each, (such as, gel cell, absorbed glassmat)
E2363	NU	Power wheelchair accessory, group 24 sealed lead acid battery, each (such as, gel cell, absorbed glassmat)
E2366	NU	Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or nonsealed, each
E2367	NU	Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or nonsealed, each
K0618		TLSO, sagittal-coronal control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphsis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
K0619		TLSO, sagittal-coronal control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphsis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
L0112		Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated
L0861		Addition to halo procedure, replacement liner/interface material
L1831		Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment
L1907		AFO, supramalleolar with straps, with or without interface/pads, custom fabricated
L1951		Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment
L1971		Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment
L5673		Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism
L5679		Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism
L5681		Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679)
L5683		Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679)
The following new HCPCS procedure codes are subject to prior authorization as authorized under section 443.6(b)(7) of the code:
E2402	RR	Negative pressure wound therapy electrical pump, stationary or portable
G0296		PET imaging, full and partial ring PET scanner only, for restaging of previously treated thyroid cancer of follicular cell origin following negative I-131 whole body scan
V2121		Lenticular lens, per lens, single
V2221		Lenticular lens, per lens, bifocal
V2321		Lenticular lens, per lens, trifocal
V2782		Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens
V2783		Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens
V2784		Lens, polycarbonate or equal, any index, per lens
The following new HCPCS procedure code is for a prosthesis and therefore subject to prior authorization under section 443.6(b)(1) of the code:
L8509		Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type

Procedure Codes Being Added to the Fee Schedule as a Result of the 2004 Updates and Additions Which are Effective and Compensable for Dates of Service as of February 7, 2005

PROCEDURE CODE and Modifiers	PROCEDURE CODE and Modifiers	PROCEDURE CODE and Modifiers	PROCEDURE CODE and Modifiers
20982 SG, 80	21685 SG, 80	22532 SG, 80	22533 SG, 80
22534 80	31632	31633	34805 80
35510 80	35512 80	35522 80	35525 80
35697 80	36555 SG, RT, LT, 50	36556 SG, LT, RT, 50	36557 SG, LT, RT, 50
36558 SG, RT, LT, 50	36560 SG, RT, LT, 50	36561 SG, RT, LT, 50	36563 SG, RT, LT, 50
36565 SG, RT, LT, 50	36566 SG, RT, LT, 50	36568 SG, RT, LT, 50	36569 SG, RT, LT, 50
36570 SG, RT, LT, 50	36571 SG, RT, LT, 50	36575 SG, RT, LT, 50	36576 SG, RT, LT, 50
36578 SG, RT, LT, 50	36580 SG, RT, LT, 50	36581 SG, RT, LT, 50	36582 SG, RT, LT, 50
36583 SG, RT, LT, 50	36584 SG, RT, LT, 50	36585 SG, RT, LT, 50	36589 SG, RT, LT, 50
36590 SG, RT, LT, 50	36595 SG, RT, LT, 50	36596 SG, RT, LT, 50	36597 SG, RT, LT, 50
36838 SG, RT, LT, 50	37765 SG, RT, LT, 50	37766 SG, RT, LT, 50	43237 SG
43238 SG	53500 SG	57425 SG, 80	59070 SG
59072 SG	59074 SG, 80	59076 SG, 80	61537 80
61540 80	61566 80	61567 80	61863 80
61864 80	61867 80	61868 80	63101 80
63102 80	63103 80	64449	64517 SG
64681 SG	65780 SG, 80	65782 SG, 80	67912 SG, RT, LT, 50
70557 26	70558 26	70559 26	75998 TC, 26
76082 TC, 26	76083 TC, 26	76514 LT, RT, TC, 26, 50	76937 TC, 26
76940 26	78804 TC, 26	79403 TC, 26	84156
84157	85055	85396	87269
87329	87660	88112 TC, 26	88361 TC, 26
89220	89225	89230	89235
90655	90698	90715	90734
95991	97755	A4216	A4217
A4366	A4416	A4417	A4418
A4419	A4420	A4423	A4424
A4425	A4426	A4427	A4428
A4429	A4430	A4434	A6407
A6441	A6442	A6443	A6444
A6445	A6446	A6447	A6448
A6449	A6450	A6451	A6452
A6453	A6454	A6455	A6456
A6550	A6551	A7046 NU	A7520
A7521	A7522	A7524	A7525
A7526	E0140 NU, RR	E0190 NU	E0240 NU
E0247 NU	E0248 NU	E0301 RR	E0302 RR
E0303 RR	E0304 RR	E0470 RR	E0471 RR
E0472 RR	E0561 NU, RR	E0562 NU, RR	E0637 NU, RR
E0638 NU, RR	E0675 RR	E0955 NU,RR	E0956 NU, RR
E0957 NU, RR	E0960 NU, RR	E0981 NU	E0982 NU
E0983 NU, RR	E0984 NU, RR	E0985 NU, RR	E1002 NU, RR
E1003 NU, RR	E1004 NU, RR	E1005 NU, RR	E1006 NU, RR
E1007 NU, RR	E1008 NU, RR	E1010 NU, RR, LT, RT, 50	E1028 NU, RR, LT, RT, 50
E1029 NU, RR	E1030 NU, RR	E1391 RR	E2201 NU, RR
E2202 NU, RR	E2203 NU, RR	E2204 NU, RR	E2310 NU, RR
E2311 NU, RR	E2320 NU, RR	E2321 NU, RR	E2322 NU, RR
E2323 NU, RR	E2324 NU, RR	E2325 NU, RR	E2326 NU, RR
E2327 NU, RR	E2328 NU, RR	E2329 NU, RR	E2330 NU, RR
E2340 NU, RR	E2341 NU, RR	E2342 NU, RR	E2343 NU, RR
E2351 NU, RR	E2360 NU, RR	E2361 NU, RR	E2362 NU, RR
E2363 NU, RR	E2364 NU, RR	E2365 NU, RR	E2366 NU, RR
E2367 NU, RR	E2402 RR	G0296 TC, 26	G0297 SG, 80
G0298 SG, 80	G0299 SG, 80	G0300 SG, 80	K0552
K0601	K0602	K0603	K0604
K0605	K0618	K0619	K0620
L0112	L0861	L1831 LT, RT, 50	L1907 LT, RT, 50
L1951 LT, RT, 50	L1971 LT, RT, 50	L3031 LT, RT, 50	L3917 LT, RT, 50
L5673 LT, RT, 50	L5679 LT, RT, 50	L5681 LT, RT, 50	L5683 LT, RT, 50
L8511	L8512	L8513	L8514
P9051 SG	P9052 SG	P9053 SG	P9054 SG
P9055 SG	P9056 SG	P9057 SG	P9058 SG
P9059 SG	P9060 SG	V2121	V2221
V2321	V2782	V2783	V2784

Procedure Codes Being Added to the Fee Schedule as a Result of Additions Which are Effective and Compensable for Dates of Service as of February 7, 2005

PROCEDURE CODE and Modifiers	PROCEDURE CODE and Modifiers
35500	L8509
P9017 SG

Procedure Codes Being End Dated From the Fee Schedule as a Result of the Updates and Which Will Not Be Compensable for Services Provided After February 6, 2005

Procedure Codes
A4621	A6421	E0142	E0145	E0146	E0165	E0975	E0976
E0979	E0991	E0993	E1066	E1069	G0236	K0016	K0022
K0025	K0026	K0027	K0028	K0029	K0030	K0031	K0032
K0033	K0035	K0036	K0048	K0049	K0054	K0055	K0057
K0058	K0062	K0063	K0079	K0080	K0082	K0083	K0084
K0085	K0086	K0087	K0088	K0089	K0100	K0103	K0107
K0112	K0113	K0268	K0531	K0532	K0533	K0534	K0541
K0542	K0543	K0544	K0549	K0550	L1885	L2102	L2104
L2122	L2124	Q9920	Q9921	Q9922	Q9923	Q9924	Q9925
Q9926	Q9927	Q9928	Q9929	Q9930	Q9931	Q9932	Q9933
Q9934	Q9935	Q9936	Q9937	Q9938	Q9939	Q9940	Y9643
Y9644	Y9963	Y9964	Y9965	Y9920	Y9921	Y9923	Y9927
Y9929	Y9931	Y9937	Z0245	Z0978	Z0979	Z4250	Z4255
Z4256	Z4257	Z4258	Z4259	Z4260	Z4261	Z4263	Z4267
Z4268	Z4271	Z4272	Z4279	Z4461	Z4465	Z6002	Z9000
Z9001	00544	36533	36534	36535	47134	61862	76085
76490	89360	90659

Local Procedure Codes Being End Dated on the Fee Schedule and Replaced With New Procedure Codes as a Result of the 2004 HCPCS Updates

END DATE FEB. 6, 2005	USE FEB. 7, 2005	END DATE FEB. 6, 2005	USE FEB. 7, 2005
Y9643	E1029	Y9643	E1030
Y9644	E1029	Y9644	E1030
Y9663	E0240	Y9664	E0240
Y9665	E0240	Y9920	E0637
Y9920	E0638	Y9921	E0637
Y9921	E0638	Y9923	E0637
Y9923	E0638	Y9927	E0955
Y9929	E0955	Y9931	E0960
Y9937	A7520	Y9937	A7520
Y9937	A7521	Y9937	A7522
Z0245	E0247	Z0245	E0248
Z0978	E0190	Z0979	E0190
Z4250	A7520	Z4250	A7521
Z4250	A7522	Z4255	A7521
Z4256	A7521	Z4257	A7521
Z4261	A7520	Z4261	A7521
Z4261	A7522	Z4263	A7520
Z4263	A7521	Z4263	A7522
Z4267	A6447	Z4268	A6445
Z4271	A6445	Z4272	A6445
Z4279	A6445	Z4280	A6442
Z4280	A6445	Z4281	A6443
Z4281	A6446	Z4282	A6443
Z4282	A6446	Z4283	A6444
Z4283	A6447	Z4269	A6446
Z4270	A6446	Z4462	A6449
Z4463	A6449	Z9800	A4217
Z4461	A6448	Z4465	A6450
Z6002	P9017	Z9001	E0190
Z4258	A7520	Z4259	A7520
Z4260	A7520	Z4260	A7521
Z4260	A7522	Z9000	A4216
Z9000	A4217

Fiscal Impact

   The estimated cost for Fiscal Year 2004-2005 is $0.555 million ($0.256 million in State funds). The estimated cost for Fiscal Year 2005-2006 is $2.220 million ($1.004 million in State funds).

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 this notice.

   Persons with a disability who require an auxiliary aid or service may submit comments using the AT&T Relay Services by calling [phone] (TDD users) or [phone] (voice users).

ESTELLE B. RICHMAN,   
Secretary

   Fiscal Note:  14-NOT-409. (1) General Fund; (2) Implementing Year 2004-05 is $256,000; (3) 1st Succeeding Year 2005-06 is $1,004,000; 2nd Succeeding Year 2006-07 is $1,007,000; 3rd Succeeding Year 2007-08 is $1,010,000; 4th Succeeding Year 2008-09 is $1,010,000; 5th Succeeding Year 2009-10 is $1,010,000; 2003-04 Program--$727,979,000; 2002-03 Program--$666,832,000; 2001-02 Program--$705,750,000; (7) Medical Assistance--Outpatient; (8) recommends adoption. The cost outlined above have been included in the General Appropriation Act of 2004 (Act 7A).

[Pa.B. Doc. No. 05-251. Filed for public inspection February 4, 2005, 9:00 a.m.]