1495 Medical Assistance Program fee schedule revisions

Medical Assistance Program Fee Schedule Revisions

Purpose of Notice

[40 Pa.B. 4716]
[Saturday, August 14, 2010]

 The Department of Public Welfare (Department) announces that it will revise the fees, or a component of the fee, on the Medical Assistance (MA) Program Fee Schedule for select medical, surgical, laboratory, durable medical equipment and radiological services effective August 30, 2010.

Fee Schedule Revisions

 The Pennsylvania Medicaid State Plan (State Plan) specifies that maximum fees for services covered under the MA Program are to be determined on the basis of the following: fees may not exceed the Medicare upper limit when applicable; fees must be consistent with efficiency, economy and quality of care; and fees must be sufficient to assure the availability of services to recipients. MA regulations at 55 Pa. Code § 1150.62(a) (relating to payment levels and notice of rate setting changes) also specify that the MA fees may not exceed the Medicare upper limit.

 The Department has determined that MA fees for approximately 200 medical, surgical, laboratory, durable medical equipment and radiological procedure codes or combinations of procedure codes and modifiers, are above the Medicare upper limit for the same procedure codes. The Department is adjusting the fees on the MA Program Fee Schedule for these combinations of procedure codes and modifiers to equal the Medicare upper limit. Revision of these fees is necessary to comply with the regulation and State Plan, and to avoid a Federal disallowance. When adjusting the assistant surgeon fee (modifier 80), the Department followed the Medicare guidelines of paying 16% of the maximum allowable payment to a primary surgeon, as MA fees may not exceed the Medicare upper limit.

 As set forth as follows, the Department has revised the total fee (billed with no modifier) and, as applicable, the professional component fee (billed with modifier 26), the technical component fee (billed with modifier TC), the assistant surgeon fee (billed with modifier 80), and the fee when billing for the rental (RR) of durable medical equipment. ''N/A'' indicates that the modifier is not on the MA Program Fee Schedule for the procedure code. ''N/C'' indicates that there is no change in the fee associated with the modifier:

Procedure Code	Procedure Code Description	Assistant Surgeon Fee Revision (Billing with Modifier 80)	Professional Component Fee Revision (Billing with Modifier 26)	Technical Component Fee Revision (Billing with Modifier TC)	Billing with No Modifier or with Pricing Modifier RR
20902	Bone graft, any donor area; major or large	$50.72	N/A	N/A	$317.02
25335	Centralization of wrist on ulna (for example, radial club hand)	N/A	N/A	N/A	$821.71
27250	Closed treatment of hip dislocation, traumatic; without anesthesia	N/A	N/A	N/A	$209.74
33141	Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open cardiac procedure(s) (List separately in addition to code for primary procedure)	$22.97	N/A	N/A	$143.59
36593	Declotting by thrombolytic agent of implanted vascular access device or catheter	N/A	N/A	N/A	$25.06
52400	Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive hypertrophic mucosal folds	N/A	N/A	N/A	$486.41
52640	Transurethral resection; of postoperative bladder neck contracture	N/A	N/A	N/A	$303.47
55873	Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring)	N/A	N/A	N/A	$881.64
64416	Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement)	N/A	N/A	N/A	$81.36
64446	Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement)	N/A	N/A	N/A	$83.45
64448	Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement)	N/A	N/A	N/A	$73.78
64449	Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement)	N/A	N/A	N/A	$84.14
70140	Radiologic examination, facial bones; less than 3 views	N/A	$9.33	$18.11	$27.44
70260	Radiologic examination, skull; complete, minimum of 4 views	N/A	$15.98	$27.49	N/C
70355	Orthopantogram	N/A	$10.38	$10.47	$20.85
70371	Complex dynamic pharyngeal and speech evaluation by cine or video recording	N/A	$40.81	$48.34	$89.15
72070	Radiologic examination, spine; thoracic, 2 views	N/A	$10.75	$20.19	N/C
73542	Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation	N/A	$28.33	$45.90	$74.23
74485	Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation	N/A	$27.21	$77.52	$104.73
75630	Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation	N/A	$90.94	$167.16	$258.10
75962	Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation	N/A	$26.86	$192.87	$219.73
75964	Transluminal balloon angioplasty, each additional peripheral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure)	N/A	$18.68	$115.74	$134.42
75966	Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation	N/A	$67.28	$197.39	$264.67
75968	Transluminal balloon angioplasty, each additional visceral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure)	N/A	$18.24	$114.35	$132.59
75978	Transluminal balloon angioplasty, venous (for example, subclavian stenosis), radiological supervision and interpretation	N/A	$26.86	$190.79	$217.65
76098	Radiological examination, surgical specimen	N/A	$8.24	$10.47	$18.71
76511	Ophthalmic ultrasound, diagnostic; quantitative A-scan only	N/A	$32.29	$43.47	N/C
76512	Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan)	N/A	$40.58	$36.52	N/C
76529	Ophthalmic ultrasonic foreign body localization	N/A	$28.99	$35.83	N/C
76811	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation	N/A	$92.69	$91.42	$184.11
76819	Fetal biophysical profile; without non-stress testing	N/A	$36.84	$48.68	N/C
76820	Doppler velocimetry, fetal; umbilical artery	N/A	$24.33	$22.28	$46.61
76827	Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete	N/A	$28.26	$36.18	$64.44
76828	Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study	N/A	$27.20	$20.54	$47.74
76946	Ultrasonic guidance for amniocentesis, imaging supervision and interpretation	N/A	$18.61	$19.85	$38.46
76977	Ultrasound bone density measurement and interpretation, peripheral site(s), any method	N/A	$2.89	$8.38	$11.27
77003	Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction	N/A	$22.10	$28.19	N/C
77012	Computed tomography guidance for needle placement (for example, biopsy, aspiration, injection, localization device), radiological supervision and interpretation	N/A	$57.61	$107.75	$165.36
77031	Stereotactic localization guidance for breast biopsy or needle placement (for example, for wire localization or for injection), each lesion, radiological supervision and interpretation	N/A	$80.33	$84.47	$164.80
77032	Mammographic guidance for needle placement, breast (for example, for wire localization or for injection), each lesion, radiological supervision and interpretation	N/A	$23.55	$26.45	N/C
77051	Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure)	N/A	$3.25	$8.03	$11.28
77052	Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure)	N/A	$3.25	$8.03	$11.28
77053	Mammary ductogram or galactogram, single duct, radiological supervision and interpretation	N/A	$17.89	$47.99	$65.88
77054	Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation	N/A	$22.57	$66.06	$88.63
77077	Joint survey, single view, 2 or more joints (specify)	N/A	$13.42	$23.32	N/C
77079	Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (for example, radius, wrist, heel)	N/A	$10.76	$39.65	$50.41
77081	Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (for example, radius, wrist, heel)	N/A	$10.76	$16.72	$27.48
77083	Radiographic absorptiometry (for example, photodensitometry, radiogrammetry), 1 or more sites	N/A	$9.69	$14.29	$23.98
77295	Therapeutic radiology simulation-aided field setting; 3-dimensional	N/A	$229.56	$348.96	$578.52
77305	Teletherapy, isodose plan (whether hand or computer calculated); simple (1 or 2 parallel opposed unmodified ports directed to a single area of interest)	N/A	$20.54	$30.96	N/C
77333	Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus)	N/A	$42.25	$19.50	$61.75
77417	Therapeutic radiology port film(s)	N/A	N/A	N/A	$14.29
77620	Hyperthermia generated by intracavitary probe(s)	N/A	$74.83	$110.00	N/C
78320	Bone and/or joint imaging; tomographic (SPECT)	N/A	$51.93	$175.20	$227.13
78710	Kidney imaging morphology; tomographic (SPECT)	N/A	$32.19	$173.81	$206.00
78730	Urinary bladder residual study (List separately in addition to code for primary procedure)	N/A	$8.23	$35.99	N/C
79200	Radiopharmaceutical therapy, by intracavitary administration	N/A	$70.58	$62.93	N/C
79403	Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion	N/A	$113.13	$88.34	$201.47
80047	Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520)	N/A	N/A	N/A	$12.12
86490	Skin test; coccidioidomycosis	N/A	N/A	N/A	$5.95
88182	Flow cytometry, cell cycle or DNA analysis	N/A	$34.81	$6.50	N/C
88355	Morphometric analysis; skeletal muscle	N/A	$84.64	$31.63	N/C
88358	Morphometric analysis; tumor (for example, DNA ploidy)	N/A	$42.70	$19.79	N/C
91022	Duodenal motility (manometric) study	N/A	$62.13	$95.94	N/C
91034	Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretation	N/A	$40.72	$131.38	N/C
91040	Esophageal balloon distension provocation study	N/A	$51.06	$280.08	$331.14
92547	Use of vertical electrodes (List separately in addition to code for primary procedure)	N/A	N/A	N/A	$4.21
92565	Stenger test, pure tone	N/A	N/A	N/A	$11.51
92577	Stenger test, speech	N/A	N/A	N/A	$14.29
92586	Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited	N/A	$22.95	$34.42	$57.37
92587	Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)	N/A	$6.81	$26.80	$33.61
92588	Evoked otoacoustic emissions; comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)	N/A	$18.24	$39.65	$57.89
92977	Thrombolysis, coronary; by intravenous infusion	N/A	N/A	N/A	$97.72
93000	Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report	N/A	N/A	N/A	$19.42
93005	Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report	N/A	N/A	N/A	$10.47
93015	Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report	N/A	N/A	N/A	$90.07
93224	Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation	N/A	N/A	N/A	$102.27
93226	Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original waveform recording and storage, with visual superimposition scanning; scanning analysis with report	N/A	N/A	N/A	$44.86
93230	Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; includes recording, microprocessor-based analysis with report, physician review and interpretation	N/A	N/A	N/A	$104.01
93232	Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; microprocessor-based analysis with report	N/A	N/A	N/A	$49.03
93270	Wearable patient activated electrocardiographic rhythm derived event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time; recording (includes connection, recording, and disconnection)	N/A	N/A	N/A	$16.02
93278	Signal-averaged electrocardiography (SAECG), with or without ECG	N/A	$12.89	$21.58	$34.47
93320	Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete	N/A	$19.96	$45.21	N/C
93321	Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study (List separately in addition to codes for echocardiographic imaging)	N/A	$8.23	$21.24	$29.47
93555	Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography	N/A	$42.86	$45.90	$88.76
93556	Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass)	N/A	$43.93	$76.83	$120.76
93724	Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings)	N/A	$258.62	$49.03	$307.65
94761	Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (for example, during exercise)	N/A	N/A	N/A	$3.86
95927	Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head	N/A	$26.82	$32.66	N/C
96110	Developmental testing; limited (for example, Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report	N/A	N/A	N/A	$6.99
E0424	Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing	N/A	N/A	N/A	$173.17 RR
E0439	Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask and tubing	N/A	N/A	N/A	$173.17 RR
E1390	Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate	N/A	N/A	N/A	$173.17 RR
E1391	Oxygen concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, each	N/A	N/A	N/A	$173.17 RR
E1405	Oxygen and water vapor enriching system with heated delivery	N/A	N/A	N/A	$209.99 RR
E1406	Oxygen and water vapor enriching system without heated delivery	N/A	N/A	N/A	$190.08 RR
Q0035	Cardiokymography	N/A	$8.26	$9.77	$18.03

Fiscal Impact

 It is anticipated that these revisions will result in savings of $0.368 million ($0.154 million in State funds) in the MA Outpatient Program in Fiscal Year 2010-2011 and annualized savings of $0.552 million ($0.250 million in State funds) in Fiscal Year 2011-2012. These State fund estimates are based on the increased Federal Medical Assistance Percentages, applicable through December 2010, as determined under the American Recovery and Reinvestment Act (ARRA) of 2009.

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 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 Pennsylvania AT&T Relay Service at [phone] (TDD users) or [phone] (voice users).

HARRIET DICHTER, 
Secretary

 Fiscal Note: 14-NOT-655. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 10-1495. Filed for public inspection August 13, 2010, 9:00 a.m.]