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Home » 2008 Issues » Vol. 38, No. 10 (03/08/2008) » 420 Medical Assistance program fee schedule revisions; 2007 HCPCS updates; prior authorization requirements

  420 Medical Assistance program fee schedule revisions; 2007 HCPCS updates; prior authorization requirements  

  • DEPARTMENT OF PUBLIC WELFARE

    Medical Assistance Program Fee Schedule Revisions; 2007 HCPCS Updates; Prior Authorization Requirements

    [38 Pa.B. 1222]
    [Saturday, March 8, 2008]

       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 March 15, 2008.

    Fee Schedule Revisions

       The Department is adding and end-dating procedure codes as a result of implementing the 2007 updates made by the Centers for Medicare and Medicaid Services to the Healthcare Common Procedure Coding System (HCPCS). The Department is also adding procedure codes, and procedure code and modifier combinations, to the MA Program Fee Schedule as a result of significant program exception requests.

       Fees for the new procedure codes, and procedure code and modifier combinations, will be published in a Medical Assistance Bulletin that will be issued to all providers.

       Procedure codes being added to the MA Program Fee Schedule as a result of the 2007 HCPCS updates which are effective and compensable for dates of service as of March 15, 2008.

    Procedure Code
    and Modifiers     		Procedure Code
    and Modifiers     		Procedure Code
    and Modifiers     		Procedure Code
    and Modifiers
    00625 35303 67346 (SG) 77078 (26)
    00626 35303 (80) 72291 (26) 77078 (TC)
    15002 35304 72292 (26) 77079
    15002 (SG) 35304 (80) 76776 77079 (26)
    15003 35305 76776 (26) 77079 (TC)
    15004 35305 (80) 76776 (TC) 77080
    15004 (SG) 35306 76813 77080 (26)
    15005 35306 (80) 76813 (26) 77080 (TC)
    15731 35537 76813 (TC) 77081
    15731 (SG) 35537 (80) 76814 77081 (26)
    15830 35538 76814 (26) 77081 (TC)
    15830 (80) 35538 (80) 76814 (TC) 77083
    15830 (SG) 35539 76998 (26) 77083 (26)
    15847 35539 (80) 77001 77083 (TC)
    15847 (80) 35540 77001 (26) 77084
    17311 35540 (80) 77001 (TC) 77084 (26)
    17312 35637 77002 77084 (TC)
    17313 35637 (80) 77002 (26) 77371
    17314 35638 77002 (TC) 77372
    17315 35638 (80) 77003 77373
    19105 35883 77003 (26) 77435
    19300 35883 (80) 77003 (TC) 82107
    19300 (SG) 35884 77011 83698
    19301 35884 (80) 77011 (26) 83913
    19301 (SG) 37210 77011 (TC) 86788
    19302 37210 (SG) 77012 86789
    19302 (80) 44157 77012 (26) 87305
    19302 (SG) 44157 (80) 77012 (TC) 87498
    19303 44158 77013 (26) 87640
    19303 (80) 44158 (80) 77014 87641
    19303 (SG) 47719 77014 (26) 87653
    19304 47719 (80) 77014 (TC) 87808
    19304 (80) 48105 7702191111
    19304 (SG) 48105 (80) 77021 (26) 91111 (26)
    19305 48548 77021 (TC) 91111 (TC)
    19305 (80) 48548 (80) 77022 (26) 92025
    19306 49324 77031 92025 (26)
    19306 (80) 49324 (80) 77031 (26) 92025 (TC)
    19307 49324 (SG) 77031 (TC) 94002
    19307 (80) 49325 77032 94003
    25109 49325 (80) 77032 (26) 94610
    25109 (SG) 49325 (SG) 77032 (TC) 94644
    25606 49326 77051 94645
    25606 (SG) 49326 (80) 77051 (26) 94777
    25607 49402 77051 (TC) 96040
    25607 (80) 49402 (SG) 77052 A4461
    25607 (SG) 49435 77052 (26) A4463
    25608 49435 (80) 77052 (TC) A4600
    25608 (80) 49436 77053 A8000
    25608 (SG) 49436 (80) 77053 (26) A8001
    25609 49436 (SG) 77053 (TC) A8002
    25609 (80) 54865 77054 A8003
    25609 (SG) 54865 (SG) 77054 (26) A8004
    27325 55875 77054 (TC) D0273
    27325 (80) 55875 (SG) 77055 D1206
    27325 (SG) 55876 77055 (26) D1555
    27326 55876 (SG) 77055 (TC) G0392
    27326 (80) 56442 77056 G0392 (SG)
    27326 (SG) 56442 (SG) 77056 (26) G0393
    28055 57296 77056 (TC) G0393 (SG)
    28055 (SG) 57296 (80) 77057 G0394
    32998 57558 77057 (26) J7345
    32998 (80) 57558 (SG) 77057 (TC) K0738 (RR)
    32998 (SG) 58541 77058 L1001
    33202 58541(80) 77058 (26) L3806
    33203 58541 (SG) 77058 (TC) L3808
    33254 58542 77059 L3915
    33254 (80) 58542 (80) 77059 (26) L6611
    33255 58542 (SG) 77059 (TC) L6624
    33255 (80) 58543 77072 L6639
    33256 58543 (80) 77072 (26) L6703
    33256 (80) 58543 (SG) 77072 (TC) L6704
    33265 58544 77073 L6706
    33265 (80) 58544 (80) 77073 (26) L6707
    33266 58544 (SG) 77073 (TC) L6708
    33266 (80) 58548 77074 L6709
    33675 58548 (80) 77074 (26) L7007
    33675 (80) 58957 77074 (TC) L7008
    33676 58957 (80) 77075 L7009
    33676 (80) 58958 77075 (26) L8691
    33677 58958 (80) 77075 (TC) Q4081
    33677 (80) 64910 77076 T4543
    33724 64910 (80) 77076 (26)
    33724 (80) 64910 (SG) 77076 (TC)
    33726 64911 77077
    33726 (80) 64911 (80) 77077 (26)
    35302 64911 (SG) 77077 (TC)
    35302 (80) 67346 77078

       Procedure codes being end-dated from the MA Program Fee Schedule as a result of the 2007 HCPCS updates and which will not be compensable for services provided after March 14, 2008:

    Procedure Codes
    15000 31708 76003 76355 L0110 L6808
    15001 31710 76005 76360 L3902 L6809
    15831 33200 76012 76362 L3914 L6825
    17304 33201 76013 76370 L6700 L6830
    17305 33245 76020 76393 L6705 L6835
    17306 33246 76040 76394 L6710 L6840
    17307 33253 76061 76400 L6715 L6845
    17310 35381 76062 76778 L6720 L6850
    19140 35507 76065 76986 L6725 L6855
    1916035541 76066 78704 L6730 L6860
    19162 35546 76071 78715 L6735 L6865
    19180 35641 76075 78760 L6740 L6867
    19182 44152 76077 91060 L6745 L6868
    19200 44153 76082 92573 L6750 L6870
    19220 47716 76083 94656 L6755 L6872
    19240 48005 76086 94657 L6765 L6873
    21300 48180 76088 A4348 L6770 L6875
    25611 49085 76090 A4359 L6775 L6880
    25620 54152 76091 E0164 L6780 L7010
    26504 54820 76092 E0166 L6790 L7015
    27315 56720 76093 E0180 L6795 L7020
    27320 57820 76094 E0701 L6800 L7025
    28030 67350 76095 E0977 L6806 L7030
    31700 75998 76096 L0100 L6807 L7035

       Procedure codes being added by the Department to the MA Program Fee Schedule as a result of significant program exception requests, which are effective and compensable for dates of service as of March 15, 2008.

    Procedure Code
    and Modifiers     		Procedure Code
    and Modifiers     		Procedure Code
    and Modifiers     		Procedure Code
    and Modifiers
    17111 59514 78608 95810 (TC)
    17111 (SG) 59514 (80) 78608 (26) 95811
    43644 59820 (U7) 78608 (TC) 95811 (26)
    43644 (80) 69710 86361 95811 (TC)
    43770 69710 (80) 92135 95930
    43770 (80) 69710 (SG) 92135 (26) 95930 (26)
    43771 69711 92135 (TC) 95930 (TC)
    43771 (80) 69711 (80) 92250 99239
    43772 69711 (SG) 92250 (26) A4231
    43772 (80) 69714 92250 (TC) A4230
    43773 69714 (SG) 95805 (26) C1300
    43773 (80) 69715 95805 (TC) E0619 (RR)
    43774 69715 (SG) 95807 (26) S3818
    43774 (80) 69717 95807 (TC) S3819
    59025 (26) 69717 (SG) 95808 (26) S3820
    59025 (TC) 69718 95808 (TC) S3822
    59409 69718 (SG) 95810 (26) S3823

    Prior Authorization Requirements

       The Department has determined that the following procedure codes currently on the MA Program Fee Schedule will require prior authorization, as authorized under section 443.6(b)(7) (relating to reimbursement for certain medical assistance items and services) of the act of June 13, 1967 (P. L. 31, No. 21) (62 P. S. §§ 101--1503) known as Public Welfare Code (code):

    72159 Magnetic resonance angiography, spinal canal and contents, with or without contrast materials
    72198 Magnetic resonance angiography, pelvis, with or without contrast materials
    73225 Magnetic resonance angiography, upper extremity, with or without contrast materials
    76936 Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae    (includes diagnostic ultrasound evaluation, compression of lesion and imaging)
    78647 Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT)
    78807 Radiopharmaceutical localization of inflammatory process; tomographic (SPECT)

       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 Public Welfare Code (code) (62 P. S. § 443.6(b)(1)), as amended by the act of July 7, 2005 (P. L. 177, No. 42).

    L1001 Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting and    adjustment
    L3806 Wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may    include soft interface material, straps, custom fabricated, includes fitting and adjustment
    L3808 Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom    fabricated, includes fitting and adjustment
    L3915 Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include    soft interface, straps, prefabricated, includes fitting and adjustment
    L6611 Addition to upper extremity prosthesis, external powered, additional switch, any type
    L6624 Upper extremity addition, flexion/extension and rotation wrist unit
    L6639 Upper extremity addition, heavy duty feature, any elbow
    L6703 Terminal device, passive hand/mitt, any material, any size
    L6704 Terminal device, sport/recreational/work attachment, any material, any size
    L6706 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined
    L6707 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined
    L6708 Terminal device, hand, mechanical, voluntary opening, any material, any size
    L6709 Terminal device, hand, mechanical, voluntary closing, any material, any size
    L7007 Electric hand, switch or myoelectric controlled, adult
    L7008 Electric hand, switch or myoelectric, controlled, pediatric
    L7009 Electric hook, switch or myoelectric controlled, adult
    L8691 Auditory osseointegrated device, external sound processor, replacement

       The Department has determined that the following new procedure codes being added to the MA Program Fee Schedule will require prior authorization as authorized under § 443.6(b)(7) of the code:

    Procedure Code Procedure Description
    C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
    15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical    panniculectomy
    15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g.,    abdominoplasty) (includes umbilical transposition and fascial plication) (list separately in
       addition to code for primary procedure)
    19300 Mastectomy for gynecomastia
    19304 Mastectomy, subcutaneous
    43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y    gastroenterostomy (roux limb 150 cm or less)
    43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric    band and subcutaneous port components)
    43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric band component    only
    43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band component    only
    43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric    band component only
    43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band and    subcutaneous port components
    69710 Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone
    69711 Removal or repair of electromagnetic bone conduction hearing device in temporal bone
    69714 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external    speech processor/cochlear stimulator; without mastoidectomy
    69715 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy
    69717 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with    percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy
    69718 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with    percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy
    78608 Brain imaging, positron emission tomography (PET); metabolic evaluation

       The following procedure code being added to the MA Program Fee Schedule is durable medical equipment and will require prior authorization, as authorized under § 443.6(b)(3) of the code:

    E0619 (RR) Apnea monitor, with recording feature

    Fiscal Impact

       The estimated cost for Fiscal Year 2007-2008 is $0.537 million ($0.254 million in State funds). The estimated cost for Fiscal Year 2008-2009 is $3.220 ($1.515 million in State funds).

    Public Comment

       Interested persons are invited to submit written comments regarding this notice to the Department at the following address: 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 AT&T Relay Service (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).

    ESTELLE B. RICHMAN,   
    Secretary

       Fiscal Note: 14-NOT-543. (1) General Fund:

    MA-Outpatient
    (2)Implementing Year 2007-08 is $254,000
    (3) 1st Succeeding Year 2008-09 is $1,515,000
    2nd Succeeding Year 2009-10 is $1,515,000
    3rd Succeeding Year 2010-11 is $1,515,000
    4th Succeeding Year 2011-12 is $1,515,000
    5th Succeeding Year 2012-13 is$1,515,000
    (4)2006-07 Program-- $671,472,000
    2005-06 Program-- $945,950,000
    2004-05 Program-- $842,991,000

       (7)  Medical Assistance Outpatient; (8) recommends adoption. Funds have been included in the budget to cover these increases.

    [Pa.B. Doc. No. 08-420. Filed for public inspection March 7, 2008, 9:00 a.m.]

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