1093 Medical Assistance Program fee schedule revisions; 2009 HCPCS updates; prior authorization requirements?
DEPARTMENT OF PUBLIC WELFARE Medical Assistance Program Fee Schedule Revisions; 2009 HCPCS Updates; Prior Authorization Requirements [40 Pa.B. 3172]
[Saturday, June 12, 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 June 14, 2010.
Fee Schedule Revisions
The Department is adding and end-dating procedure codes as a result of implementing the 2009 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, including some codes previously end-dated by CMS. Additionally, the Department is adding procedure codes to the MA Program Fee Schedule as a result of significant program exception requests. Finally, as set forth as follows, 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 2009 HCPCS updates:
Procedure Codes and Modifiers 00211 00567 20696 20696 (SG) 20696 (80) 20697 20697 (SG) 20697 (80) 27027 27057 35535 35535 (80) 35570 35570 (80) 35632 35632 (80) 35633 35633 (80) 35634 35634 (80) 43273 43279 43279 (80) 46930 46930 (SG) 49652 49652 (SG) 49652 (80) 49653 49653 (SG) 49653 (80) 49654 49654 (SG) 49654 (80) 49655 49655 (SG) 49655 (80) 49656 49656 (SG) 49656 (80) 49657 49657 (SG) 49657 (80) 61796 61797 61798 61799 62267 62267 (SG) 63620 63621 64455 64632 65756 65756 (SG) 65756 (80) 77785 77785 (26) 77785 (TC) 77786 77786 (26) 77786 (TC) 77787 77787 (26) 77787 (TC) 83951 85397 87905 88720 88740 88741 93228 93279 93279 (26) 93279 (TC) 93280 93280 (26) 93280 (TC) 93281 93281 (26) 93281 (TC) 93282 93282 (26) 93282 (TC) 93283 93283 (26) 93283 (TC) 93284 93284 (26) 93284 (TC) 93285 93285 (26) 93285 (TC) 93288 93288 (26) 93288 (TC) 93289 93289 (26) 93289 (TC) 93292 93292 (26) 93292 (TC) 93293 93293 (26) 93293 (TC) 93294 93295 93296 93306 93306 (26) 93306 (TC) 96360 96361 96365 96366 96367 96368 96369 96370 96371 96372 96373 96374 96375 99460 99461 99462 99463 99465 99468 99469 99471 99472 99475 99476 99478 99479 99480 A6545 E2231 (NU) G0412 G0412 (80) G0413 G0413 (SG) G0413 (80) G0414 G0414 (80) G0415 G0415 (80) K0672 L0113 L6711 L6712 L6713 L6714 L6721 L6722 Q4101 Q4106 The following procedure codes are being added to the MA Program Fee Schedule as a result of significant program exception requests:
Procedure Codes and Modifiers 44626 44626 (80) 51700 86480 92060 92060 (26) 92060 (TC) 95870 95870 (26) 95870 (TC) 95934 95934 (26) 95934 (TC) 95936 95936 (26) 95936 (TC) 99315 99316 A4332 A4361 E0463 (RR) E0667 (NU) E0667 (RR) E0668 (NU) E0668 (RR) E0784 (NU) E0970 (NU) E0994 (NU) E1037 (NU) E1037 (RR) E1050 (NU) E1050 (RR) E1070 (NU) E1070 (RR) E1083 (NU) E1083 (RR) E1084 (NU) E1084 (RR) E1085 (NU) E1085 (RR) E1086 (NU) E1086 (RR) E1087 (NU) E1087 (RR) E1088 (NU) E1088 (RR) E1089 (NU) E1089 (RR) E1090 (NU) E1090 (RR) E1092 (NU) E1092 (RR) E1093 (NU) E1093 (RR) E1100 (NU) E1100 (RR) E1110 (NU) E1110 (RR) E1130 (NU) E1130 (RR) E1140 (NU) E1140 (RR) E1150 (NU) E1150 (RR) E1160 (NU) E1160 (RR) E1170 (NU) E1170 (RR) E1171 (NU) E1171 (RR) E1172 (NU) E1172 (RR) E1180 (NU) E1180 (RR) E1190 (NU) E1190 (RR) E1195 (NU) E1195 (RR) E1200 (NU) E1200 (RR) E1221 (NU) E1221 (RR) E1222 (NU) E1222 (RR) E1227 (NU) E1227 (RR) E1240 (NU) E1240 (RR) E1260 (NU) E1260 (RR) E1280 (NU) E1280 (RR) E1285 (NU) E1285 (RR) E1290 (NU) E1290 (RR) E1295 (NU) E1295 (RR) E1296 (NU) E1297 (NU) E1353 L2035 L2430 L5685 L5702 L5814 S1040 V2715 The following procedure codes are being end-dated from the MA Program Fee Schedule either as a result of the 2009 HCPCS updates or because they were previously end-dated by CMS:
Procedure Codes 46934 46935 46936 52606 52612 52614 52620 61793 77781 77782 77783 77784 88400 90760 90761 90765 90766 90767 90768 90772 90773 90774 90775 93731 93732 93733 93734 93735 93736 93741 93742 93743 93744 93760 93762 99295 99296 99298 99299 99300 99431 99432 99433 99435 99440 0031T G0297 G0300 J7340 J7342 L2860 L5995 Q0001 S2075 S2076 S2077 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 act of June 13, 1967 (P. L. 31, No. 21) (62 P. S. §§ 101—1503), known as the Public Welfare Code (Code), as amended by the act of July 7, 2005 (P. L. 177, No. 42):
Procedure
Code
Procedure Description
K0672 Addition to lower extremity orthotic, removable soft interface, all components, replacement only, each L0113 Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment L2035 Knee-ankle-foot orthotic (KAFO), full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment L2430 Addition to knee joint, ratchet lock for active and progressive knee extension, each joint L5685 Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each L5702 Replacement, socket, hip disarticulation, including hip joint, molded to patient model L5814 Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock L6711 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric L6712 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric L6713 Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric L6714 Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric L6721 Terminal device, hook or hand, heavy-duty, mechanical, voluntary opening, any material, any size, lined or unlined L6722 Terminal device, hook or hand, heavy-duty, mechanical, voluntary closing, any material, any size, lined or unlined S1040 Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) The following procedure codes being added to the MA Program Fee Schedule are durable medical equipment (DME) and will require prior authorization, as authorized under § 443.6(b)(2) of the Code, as amended by the act of July 7, 2005 (P. L. 177, No. 42):
Procedure
CodeProcedure Description
E0784 (NU) External ambulatory infusion pump, insulin E1037 (NU) Transport chair, pediatric size E1050 (NU) Fully-reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg rests E1070 (NU) Fully-reclining wheelchair, detachable arms (desk or full-length) swing-away detachable footrest E1083 (NU) Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests E1084 (NU) Hemi-wheelchair, detachable arms desk or full-length arms, swing-away detachable elevating leg rests E1085 (NU) Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests E1086 (NU) Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable footrests E1087 (NU) High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevated leg rests E1088 (NU) High strength lightweight wheelchair, detachable arms desk or full-length, swing-away detachable elevating leg rests E1089 (NU) High-strength lightweight wheelchair, fixed-length arms, swing-away detachable footrest E1090 (NU) High-strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable footrests E1092 (NU) Wide heavy-duty wheelchair, detachable arms, (desk or full-length), swing-away detachable elevating leg rests E1093 (NU) Wide heavy-duty wheelchair, detachable arms, desk or full-length), swing-away detachable footrests E1100 (NU) Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg rests E1110 (NU) Semi-reclining wheelchair, detachable arms (desk or full length) elevating leg rest E1150 (NU) Wheelchair, detachable arms, desk or full-length swing-away detachable elevating leg rests E1170 (NU) Amputee wheelchair, fixed full-length arms, swing-away detachable elevating leg rests E1172 (NU) Amputee wheelchair, detachable arms (desk or full-length) without footrests or leg rest E1180 (NU) Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable footrests E1190 (NU) Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable elevating leg rests E1195 (NU) Heavy-duty wheelchair, fixed full-length arms, swing-away detachable elevating leg rests E1200 (NU) Amputee wheelchair, fixed full-length arms, swing-away detachable footrest E1240 (NU) Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable, elevating leg rest E1260 (NU) Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest E1280 (NU) Heavy-duty wheelchair, detachable arms (desk or full-length) elevating leg rests E1285 (NU) Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest E1290 (NU) Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest E1295 (NU) Heavy-duty wheelchair, fixed full-length arms, elevating leg rest Rental of the following DME, which is being added to the MA Program Fee Schedule, will require prior authorization beginning with the first month of rental, as authorized under section 443.6(b)(3) of the Code, as amended by the act of July 7, 2005 (P. L. 177, No. 42):
Procedure
CodeProcedure Description
E0463 (RR) Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (for example, tracheostomy tube) Rentals of the following DME, which are being added to the MA Program Fee Schedule, will require prior authorization after the first month's rental, as authorized under section 443.6(b)(3) of the Code, as amended by the act of July 7, 2005 (P. L. 177, No. 42):
Procedure
CodeProcedure Description
E0667 (RR) Segmental pneumatic appliance for use with pneumatic compressor, full leg E0668 (RR) Segmental pneumatic appliance for use with pneumatic compressor, full arm Rentals of the following DME, which are being added to the MA Program Fee Schedule, will require prior authorization after 3 months of rental as authorized under section 443.6(b)(3) of the code, as amended by the act of July 7, 2005 (P. L. 177, No. 42):
Procedure
CodeProcedure Description
E1037 (RR) Transport chair, pediatric size E1050 (RR) Fully-reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg rests E1070 (RR) Fully-reclining wheelchair, detachable arms (desk or full-length) swing-away detachable footrest E1083 (RR) Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests E1084 (RR) Hemi-wheelchair, detachable arms desk or full-length arms, swing-away detachable elevating leg rests E1085 (RR) Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests E1086 (RR) Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable footrests E1087 (RR) High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevated leg rests E1088 (RR) High strength lightweight wheelchair, detachable arms desk or full-length, swing-away detachable elevating leg rests E1089 (RR) High-strength lightweight wheelchair, fixed-length arms, swing-away detachable footrest E1090 (RR) High-strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable footrests E1092 (RR) Wide heavy-duty wheelchair, detachable arms, (desk or full-length), swing-away detachable elevating leg rests E1093 (RR) Wide heavy-duty wheelchair, detachable arms, desk or full-length), swing-away detachable footrests E1100 (RR) Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg rests E1110 (RR) Semi-reclining wheelchair, detachable arms (desk or full length) elevating leg rest E1130 (RR) Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests E1140 (RR) Wheelchair, detachable arms, desk or full-length, swing-away detachable footrests E1150 (RR) Wheelchair, detachable arms, desk or full-length swing-away detachable elevating leg rests E1160 (RR) Wheelchair, fixed full-length arms, swing-away detachable elevating leg rests E1170 (RR) Amputee wheelchair, fixed full-length arms, swing-away detachable elevating leg rests E1171 (RR) Amputee wheelchair, fixed full-length arms, without footrests or leg rest E1172 (RR) Amputee wheelchair, detachable arms (desk or full-length) without footrests or leg rest E1180 (RR) Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable footrests E1190 (RR) Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable elevating leg rests E1195 (RR) Heavy-duty wheelchair, fixed full-length arms, swing-away detachable elevating leg rests E1200 (RR) Amputee wheelchair, fixed full-length arms, swing-away detachable footrest E1221 (RR) Wheelchair with fixed arm, footrests E1222 (RR) Wheelchair with fixed arm, elevating leg rests E1227 (RR) Special height arms for wheelchair E1240 (RR) Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable, elevating leg rest E1260 (RR) Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest E1280 (RR) Heavy-duty wheelchair, detachable arms (desk or full-length) elevating leg rests E1285 (RR) Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest E1290 (RR) Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest E1295 (RR) Heavy-duty wheelchair, fixed full-length arms, elevating leg rest 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 the act of July 7, 2005 (P. L. 177, No. 42):
Procedure
CodeProcedure Description
Q4101 Skin substitute, Apligraf, per sq cm Q4106 Skin substitute, Dermagraft, per sq cm Fiscal Impact
The estimated cost for Fiscal Year (FY) 2010-2011 is $2.785 million ($1.017 million in State funds). The annualized cost for FY 2011-2012 is $2.906 million ($1.360 million in State funds). These State fund estimates are based on the increased Federal MA Percentages as determined under the American Recovery and Reinvestment Act (ARRA) of 2009 (42 U.S.C.A. § 5301).
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 Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
HARRIET DICHTER,
SecretaryFiscal Note: 14-NOT-641. (1) General Fund; (2) Implementing Year 2010-11 is $1,017,000; (3) 1st Succeeding Year 2011-12 is $1,360,000; 2nd Succeeding Year 2012-13 is $1,360,000; 3rd Succeeding Year 2013-14 is $1,360,000; 4th Succeeding Year 2014-15 is $1,360,000; 5th Succeeding Year 2015-16 is $1,360,000; (4) 2008-09 Program—$555,085,000; 2007-08 Program—$593,992,000; 2006-07 Program—$671,472,000; (7) MA—Outpatient; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 10-1093. Filed for public inspection June 11, 2010, 9:00 a.m.]
