DEPARTMENT OF
PUBLIC WELFAREMedical Assistance Program Fee Schedule Procedure Code Changes [36 Pa.B. 3049]
[Saturday, June 17, 2006]The Department of Public Welfare (Department) announces several changes to the Medical Assistance (MA) Program Fee Schedule effective for dates of services on or after July 17, 2006.
Fee Schedule Revisions
Local procedure code W0988 (anesthesia for electroconvulsive therapy) is being end-dated. The regulation at 55 Pa. Code § 1150.52 (relating to anesthesia services) provides that payment for anesthesia services will only be made to an enrolled practitioner qualified to administer anesthesia. National procedure codes for anesthesia services are already on the MA Program Fee Schedule and billable by an enrolled practitioner qualified to administer anesthesia.
Local procedure code W9400 (administration of chemotherapy for malignant disease, oral) is being end-dated and not replaced with a National procedure code because there have been no claims submitted using this procedure code since January 1, 2004. In addition, the regulation at 55 Pa. Code § 1221.51(1) (relating to general payment policy) provides that the fee for a clinic visit includes the administration of drugs and biologicals.
Local procedure code X1070 (removal of sutures by another physician) is being end-dated and not replaced with a National procedure code because the regulation at 55 Pa. Code § 1150.51(h)(5) precludes a separate payment for the removal of sutures. The fee for surgical services includes the removal of sutures. See 55 Pa. Code § 1150.54(a)(4)(iii) and (b)(1)(ii) (relating to surgical services).
Local procedure code X5741 (gynecological examination--asymptomatic patient) is being end-dated and not replaced with a National procedure code because the regulation at 55 Pa. Code § 1150.56(b)(1) provides that the practitioner may bill outpatient medical care as an office visit, skilled nursing or intermediate care facility visit or a home visit.
The Department is end-dating the following local procedure codes and not replacing them with National procedures because there have been no claims submitted using these procedure codes since July 1, 2004.
Local Procedure Code W9562 W9595 X1174 X2934 X2946 X3162 X4693 X5810 X5811 X5890 X5898 X6483 Y7373 Y7374 Y7375 Y7418 Y7608 Y7690 Y7696 The Department is end-dating the following National procedure codes for medical rehabilitation units of general hospitals and rehabilitation hospitals. The regulation at 55 Pa. Code § 1163.455(2) (relating to noncompensable services and items) precludes the Department from making payments to medical rehabilitation units of general hospitals and rehabilitation hospitals for inpatient services related to diagnostic tests and procedures that can be performed on an outpatient basis and diagnostic tests and procedures which are not related to the diagnoses that require that particular inpatient stay.
Procedure Code 57421 57454 57455 57456 57460 57461 58300 The Department is end-dating the following local procedure codes for acute care general hospitals, acute care general hospital based medical clinics, medical rehabilitation units of general hospitals and rehabilitation hospitals and replacing them with existing National procedure codes already on the MA Program Fee Schedule and the fees corresponding with the National procedure codes. Some of the fees for the existing National procedure codes may be higher and some may be lower than the fees for the corresponding local procedure codes.
Local
Procedure CodeLocal
Procedure CodeLocal
Procedure CodeLocal
Procedure CodeLocal
Procedure CodeW0644 W0663 W0664 W0665 W0666 W0667 W0668 W6013 W6014 W9049 W9051 W9064 W9254 W9416 W9564 W9591 W9592 W9593 W9630 W9633 W9640 W9715 W9871 W9872 X1101 X1102 X1166 X1167 X1172 X1175 X1177 X1720 X3643 X5741 X5746 Y7030 Y7100 Y7101 Y7200 Y7202 Y7211 Y7308 Y7310 Y7311 Y7312 Y7322 Y7323 Y7324 Y7325 Y7360 Y7419 Y7600 Z0832 Z2100 Z2101 Z2102 Z2103 Z2105 Z2106 Z8020 Z8227 Z8294 Z8309 Z8374 Z8391 Z8503 Z8555 Z8556 Z8557 Z8604 Z8627 Z8631 Z8636 Z8637 Z8704 Z8708 Z8712 Z8713 The Department is end-dating local procedure codes for emergency room support services, W9045, W9046, W9047 and W9048, for acute care general hospitals and acute care general hospital-based medical clinics. These codes are being replaced with five National procedure codes and associated modifiers. The crosswalk of the local codes to the National codes, which follows, and the fees assigned to the National codes, was developed using the historical MA utilization pattern of physicians performing services in the emergency room and the relative value units of severity for emergency room services used by the Centers for Medicare and Medicaid Services. The Department consulted with the Hospital and Healthsystem Association of Pennsylvania and other interested parties representing the hospital industry across this Commonwealth in developing this crosswalk and associated fees.
In addition, the Department is adding a new informational modifier associated with National procedure codes 99281 and 99282 to the MA Program Fee Schedule. Informational modifier Q6 is to be used to identify nonemergency visits to the emergency room.
Local
Procedure CodeLocal
Procedure Code MA FeeNational Procedure Code National
Procedure Code MA FeePricing Modifier Informational Modifier W9045 $35.00 99281 $ 21.00 U5 Q6 W9045 $35.00 99281 $ 21.00 U5 W9045 $35.00 99282 $ 35.00 U5 Q6 W9045 $35.00 99282 $ 35.00 U5 W9045 $35.00 99283 $ 79.00 U5 W9045 $35.00 99284 $123.00 U5 W9045 $35.00 99285 $193.00 U5 W9046 $30.00 99281 $ 16.00 U4 Q6 W9046 $30.00 99281 $ 16.00 U4 W9046 $30.00 99282 $ 30.00 U4 Q6 W9046 $30.00 99282 $ 30.00 U4 W9046 $30.00 99283 $ 74.00 U4 W9046 $30.00 99284 $118.00 U4 W9046 $30.00 99285 $188.00 U4 W9047 $105.00 99281 $ 21.00 U5 Q6 W9047 $105.00 99281 $ 21.00 U5 W9047 $105.00 99282 $ 35.00 U5 Q6 W9047 $105.00 99282 $ 35.00 U5 W9047 $105.00 99283 $ 79.00 U5 W9047 $105.00 99284 $123.00 U5 W9047 $105.00 99285 $193.00 U5 W9048 $100.00 99281 $ 16.00 U4 Q6 W9048 $100.00 99281 $ 16.00 U4 W9048 $100.00 99282 $ 30.00 U4 Q6 W9048 $100.00 99282 $ 30.00 U4 W9048 $100.00 99283 $ 74.00 U4 W9048 $100.00 99284 $118.00 U4 W9048 $100.00 99285 $188.00 U4
The Department is end-dating local procedure codes W9045, W9046, W9047 and W9048 and not replacing them with National procedure codes for medical rehabilitation units of general hospitals and rehabilitation hospitals because these providers are not enrolled in the MA Program to provide emergency room services.
MA Bulletins will be issued to acute care general hospitals, acute care general hospital-based medical clinics, medical rehabilitation units of general hospitals and rehabilitation hospitals setting forth the National procedure codes and corresponding fees that are replacing the end-dated local procedure codes. In addition, an MA Bulletin will be issued to all providers regarding the local procedure codes set forth in this notice that are being end-dated and not replaced with National procedure codes.
Services rendered on or after July 17, 2006, must be billed using the National procedure code and modifier, if appropriate.
Fiscal Impact
The conversion from local to National procedure codes, including the rates assigned to the National codes for emergency room services provided by acute care general hospitals and acute care general hospital-based medical clinics, is anticipated to have no fiscal impact.
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 revisions of the MA Program Fee Schedule.
Persons with a disability who require auxiliary aid or service may submit comments using the AT&T Relay Services at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-NOT-479. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 06-1104. Filed for public inspection June 16, 2006, 9:00 a.m.]
