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Home » 2012 Issues » Vol. 42, No. 25 (06/23/2012) » 1176 Medical Assistance Program fee schedule revisions; 2012 HCPCS updates; prior authorization requirements

  1176 Medical Assistance Program fee schedule revisions; 2012 HCPCS updates; prior authorization requirements  

  • Medical Assistance Program Fee Schedule Revisions; 2012 HCPCS Updates; Prior Authorization Requirements

    [42 Pa.B. 3704]
    [Saturday, June 23, 2012]

     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 25, 2012.

    Fee Schedule Revisions

     The Department is adding and end-dating procedure codes as a result of implementing the 2012 updates made by the Centers for Medicare and Medicaid Services (CMS) to the Healthcare Common Procedure Coding System (HCPCS). The Department is also adding and end-dating other procedure codes. 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 an MA 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 2012 HCPCS updates:

    Procedure Codes and Modifiers
    15271 15271 (SG) 15272 15273 15273 (SG)
    15274 15275 15275 (SG) 15276 15277
    15277 (SG) 15278 15777 20527 (RT) 20527 (LT)
    20527 (50) 22633 22633(80) 22634 22634 (80)
    26341 (SG) 26341 (RT) 26341 (LT) 26341 (50) 29582 (RT)
    29582 (LT) 29582 (50) 29583 (RT) 29583 (LT) 29583 (50)
    29584 (RT) 29584 (LT) 29584 (50) 32096 (RT) 32096 (LT)
    32096 (50) 32096 (80)(RT) 32096 (80)(LT) 32096 (80)(50) 32097 (RT)
    32097 (LT) 32097 (50) 32097 (80)(RT) 32097 (80)(LT) 32097(80)(50)
    32098 (RT) 32098 (LT) 32098 (50) 32098 (80)(RT) 32098(80)(LT)
    32098(80)(50) 32505 (RT) 32505 (LT) 32505 (50) 32505(80)(RT)
    32505(80)(LT) 32505(80)(50) 32506 (RT) 32506 (LT) 32506(80)(RT)
    32506(80)(LT) 32507(RT) 32507(LT) 32507(80)(RT) 32507(80)(LT)
    32607 (SG) 32607 (RT) 32607 (LT) 32607 (50) 32607(80)(RT)
    32607(80)(LT) 32607(80)(50) 32608 (SG) 32608(RT) 32608 (LT)
    32608 (50) 32608 (80)(RT) 32608(80)(LT) 32608(80)(50) 32609 (SG)
    32609 (RT) 32609 (LT) 32609 (50) 32609(80)(RT) 32609(80)(LT)
    32609(80)(50) 32666 (RT) 32666 (LT) 32666 (50) 32666(80)(RT)
    32666(80)(LT) 32666(80)(50) 32667 (RT) 32667 (LT) 32667(80)(RT)
    32667(80)(LT) 32668 (RT) 32668 (LT) 32668 (50) 32668(80)(RT)
    32668(80)(LT) 32668(80)(50) 32669 (RT) 32669 (LT) 32669 (50)
    32669(80)(RT) 32669(80)(LT) 32669(80)(50) 32670(RT) 32670(80)(RT)
    32671 (RT) 32671 (LT) 32671(80)(RT) 32671(80)(LT) 32673
    32673 (80) 32674 32674 (80) 33221 33221 (SG)
    33227 33227 (SG) 33228 33228 (SG) 33229
    33229 (SG) 33230 33230 (SG) 33231 33231 (SG)
    33262 33262 (SG) 33263 33263 (SG) 33264
    33264 (SG) 36251 36252 36253 36254
    37191 37191 (SG) 37192 37192 (SG) 37193
    37193 (SG) 37619 37619 (80) 38232 38232 (SG)
    49082 49082 (SG) 49083 49083 (SG) 49084
    49084 (SG) 62369 62370 64633(SG) 64633(RT)
    64633 (LT) 64633 (50) 64634 64635 (SG) 64635 (RT)
    64635 (LT) 64635 (50) 64636 74174 74174 (TC)
    74174 (26) 78226 78226 (TC) 78226 (26) 78227
    78227 (TC) 78227 (26) 78579 78579 (TC) 78579 (26)
    78582 78582 (TC) 78582 (26) 78597 78597 (TC)
    78597 (26) 78598 78598 (TC) 78598 (26) 86386
    87389 94726 94726 (TC) 94726 (26) 94727
    94727 (TC) 94727 (26) 94728 94728 (TC) 94728 (26)
    94729 94729 (TC) 94729 (26) 95885 95885 (TC)
    95885 (26) 95886 95886 (TC) 95886 (26) 95887
    95887 (TC) 95887 (26) 95938 95938 (TC) 95938 (26)
    95939 95939 (TC) 95939 (26) 99407 99407(FP)
    A5056 A5057 E2359 (NU) E2626(NU)(RT) E2626(NU)(LT)
    E2626(NU)(50) E2626(RR)(RT) E2626(RR)(LT) E2626(RR)(50) E2627(NU)(RT)
    E2627(NU)(LT) E2627(NU)(50) E2627(RR)(RT) E2627(RR)(LT) E2627(RR)(50)
    E2628(NU)(RT) E2628(NU)(LT) E2628(NU)(50) E2628(RR)(RT) E2628(RR)(LT)
    E2628(RR)(50) E2629(NU)(RT) E2629(NU)(LT) E2629(NU)(50) E2629(RR)(RT)
    E2629(RR)(LT) E2629(RR)(50) E2630(NU)(RT) E2630(NU)(LT) E2630(NU)(50)
    E2630(RR)(RT) E2630(RR)(LT) E2630(RR)(50) E2631(NU)(RT) E2631(NU)(LT)
    E2631(NU)(50) E2631(RR)(RT) E2631(RR)(LT) E2631(RR)(50) E2632(NU)(RT)
    E2632(NU)(LT) E2632(NU)(50) E2632(RR)(RT) E2632(RR)(LT) E2632(RR)(50)
    E2633(NU)(RT) E2633(NU)(LT) E2633(NU)(50) E2633(RR)(RT) E2633(RR)(LT)
    E2633(RR)(50) G0437 G0437(FP) L5312(RT) L5312(LT)
    L5312(50)

     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
    49496(SG) 49496 (RT) 49496 (LT) 49496 (50) 49496 (80)(RT)
    49496 (80)(LT) 49496 (80)(50) 76885 76885 (TC) 76885 (26)
    80154 80197 80201 84484 87470
    87471 87472 87475 87476 87477
    87480 87481 87482 87485 87486
    87487 87490 87492 87495 87496
    87497 A4565 E0193(RR) E0194(RR) E2609
    E2617 K0606(NU) K0606(RR)

     Additionally, the Department is adding the following procedure code and procedure code/modifier combinations back to the MA Program Fee Schedule. This procedure code was end-dated with the 2011 HCPCS update, which added the word ''unattended'' to the description. The Department's initial review indicated that unattended EEG monitoring was not an accepted standard of practice. Based upon provider requests and further review by clinical staff, the Department has revised its initial findings and is re-establishing payment for the following:

    Procedure Code
    and Modifiers     		Procedure Description
    95953
    95953 (TC)
    95953 (26)
    		Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel electroencephalographic (EEG), EEG recording and interpretation, each 24 hours, unattended

     The following procedure codes are being end-dated from the MA Program Fee Schedule either as a result of the 2012 HCPCS updates or because they were previously end-dated by CMS:

    Procedure Codes
    11975 11977 15170 15171 15175 15176
    15300 15301 15320 15321 15330 15331
    15335 15336 15340 15341 15360 15361
    15365 15366 15400 15401 15420 15421
    15430 15431 32095 32402 32500 32602
    32603 32605 32657 32660 35548 35549
    35551 35651 36488 36489 36490 36491
    36493 36530 36531 36532 37620 49080
    49081 64622 64623 64626 64627 69802
    71090 73542 75722 75724 75940 77079
    77083 78220 78223 78584 78585 78586
    78587 78588 78591 78593 78594 78596
    88107 88318 90470 92120 92130 93720
    93721 93722 93875 94240 94260 94350
    94360 94370 94720 94725 E0571 G0394
    G0430 L1500 L1510 L3964 L3965 L3966
    L3968 L3969 L3970 L3972 L3974 L5311
    L5989 L7266 L7272 L7274 L7500 S0625
    S9075

     The following local procedure code will be end-dated from the MA Program Fee Schedule. Providers should refer to the current Early and Periodic Screening, Diagnosis and Treatment Program Periodicity Schedule, available as an attachment to MA Bulletin 99-10-06, Revisions to the Early and Periodic Screening, Diagnosis and Treatment Program Periodicity Schedule, for the appropriate procedure code. The MA Bulletin may be viewed online at http://services.dpw.state.pa.us/olddpw/bulletinsearch.aspx?BulletinId=4561.

    Procedure Code Procedure Description
    W0163 Comprehensive periodic screening service—Outpatient Clinic

     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(f)), prohibits the Department from paying a provider for any medical services, procedures or drugs related to infertility therapy:

    Procedure Code Procedure Description
    58673 Laparoscopy, surgical; with salpingoscopy (salpingoneostomy)

     The following procedure code is being end-dated because it is non-specific. Providers must use the procedure codes specific to the service being provided:

    Procedure Code Procedure Description
    76380 Computed tomography, limited or localized follow-up study

     The following procedure codes, which are being end-dated from the MA Program Fee Schedule as a result of the 2012 HCPCS updates or were previously end-dated by CMS, required prior authorization approval:

    Procedure Codes
    77079 E0571 L1500 L1510
    L3964 L3965 L3966 L3968
    L3969 L3970 L3972 L3974
    L5311 L5989 L7266 L7272
    L7274 L7500

     No new authorizations will be issued for these procedure codes on and after June 25, 2012. For any of the previous procedure codes that had a prior authorization issued before June 25, 2012, providers should submit claims using the end-dated procedure code as set forth in the authorization issued by the Department. The Department will accept claims with the end-dated procedure codes until June 25, 2013, for those services that were previously prior authorized.

    Prior Authorization Requirements

     The following procedure code being added to the MA Program Fee Schedule is a prosthetic and requires 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
    L5312 Knee articulation (or through knee), molded socket, single axis knee, pylon, Sach foot, endoskeletal system

     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 section 443.6(b)(2) of the code, as amended by Act 42:

    Procedure Code Procedure Description
    E2609 Custom Fabricated Seat Cushion, any size
    E2617 Custom fabricated Wheelchair Back Cushion, any size, including any mounting hardware
    E2626 (NU) Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable
    E2627 (NU) Wheel chair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable Rancho type
    E2628 (NU) Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining
    E2629 (NU) Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (Friction dampening to proximal and distal joints
    E2630 (NU) Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support
    E2631 (NU) Wheelchair accessory, addition to mobile arm support supporting proximal arm
    E2632 (NU) Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic control
    E2633 (NU) Wheelchair accessory, addition to mobile arm support supinator
    K0606 (NU) Automatic External Defibrillator, with integrated electrocardiogram analysis

     Rentals of the following DME, which are being added to the MA Program Fee Schedule, will require prior authorization beginning with the first month's rental as authorized under section 443.6(b)(3) of the code, as amended by Act 42:

    Procedure Code Procedure Description
    E0193 (RR) Powered Air Flotation Bed (Low Air Loss Therapy)
    E0194 (RR) Air Fluidized Bed
    K0606 (RR) Automatic External Defibrillator, with integrated electrocardiogram analysis

     Rentals of the following DME, which are being added to the MA Program Fee Schedule, require prior authorization after 3 months of rental as authorized under section 443.6(b)(3) of the code, as amended by Act 42:

    Procedure Code Procedure Description
    E2626 (RR) Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced adjustable
    E2627 (RR) Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable Rancho type
    E2628 (RR) Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining
    E2629 (RR) Wheelchair accessory, shoulder elbow, mobile are support attached to wheelchair, balanced, friction arm support (Friction dampening to proximal and distal joints)
    E2630 (RR) Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support
    E2631 (RR) Wheelchair accessory, addition to mobile arm support surrounding proximal arm
    E2632 (RR) Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control
    E2633 (RR) Wheelchair accessory, addition to mobile arm support, supinator

     The following procedure codes being added to the MA Program Fee Schedule are considered advanced radiology services and will require prior authorization as authorized under section 443.6(b)(7) of the code, as amended by Act 42, and as described in MA Bulletin 99-08-08, entitled Prior Authorization of Advanced Radiologic Imaging Services, which may be viewed online at http://services.dpw.state.pa.us/olddpw/bulletinsearch.aspx?BulletinId=4377:

    Procedure Code Procedure Description
    74174 Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

    Fiscal Impact

     The estimated cost for Fiscal Year (FY) 2012-2013 is $1.689 million ($0.799 million in State funds). The annualized cost for FY 2013-2014 is $1.267 million ($0.609 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 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).

    GARY D. ALEXANDER, 
    Secretary

     Fiscal Note: 14-NOT-775. (1) General Fund; (2) Implementing Year 2011-12 is $0; (3) 1st Succeeding Year 2012-13 is $799,000; 2nd Succeeding Year 2013-14 is $609,000; 3rd Succeeding Year 2014-15 is $609,000; 4th Succeeding Year 2015-16 is $609,000; 5th Succeeding Year 2016-17 is $609,000; (4) 2010-11 Program—$467,929,000; 2009-10 Program—$435,939,000; 2008-09 Program—$555,085,000; (7) MA—Outpatient; (8) recommends adoption. Funds have been included in the budget to cover this increase.

    [Pa.B. Doc. No. 12-1176. Filed for public inspection June 22, 2012, 9:00 a.m.]

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