1607 Medical Assistance Program fee increases and additions to the Medical Assistance Program fee schedule
DEPARTMENT OF
PUBLIC WELFAREMedical Assistance Program Fee Increases and Additions to the Medical Assistance Program Fee Schedule [38 Pa.B. 4832]
[Saturday, August 30, 2008]Purpose of Notice
The Department of Public Welfare (Department) announces several changes to the Medical Assistance (MA) Program Fee Schedule, effective with dates of service on and after July 1, 2008. Consistent with the commitment of the Governor's Prescription for Pennsylvania to promote quality primary and preventive health care for all Pennsylvanians, the changes include fee increases for select office visits and consultations; vision and dental services; private duty nursing and home health agency services; and Healthy Beginnings Plus services. The Department has also added a new laboratory service and screening for developmental delay and Autism Spectrum Disorder to the Fee Schedule. The Department consulted with individual provider associations, medical and dental providers, the Medical Assistance Advisory Committee and other key stakeholders in determining which fees to increase as well as which new services to add to the Fee Schedule to support continued access to services by MA recipients.
Fee Increases
The Department has increased the fees for the following select procedure codes:
Office Visits and Consultations Procedure
CodeDescription Current
FeeMA Fee Effective July 1, 2008 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. $30.00 $35.33 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. $50.00 $54.25 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. $60.00 $90.37 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. $80.00 $117.54 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. $43.00 $54.42 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. $70.00 $78.05 99242 Office consultation for a new or established patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. $40.00 $55.15 99243 Office consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination; medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. $50.00 $76.93 99244 Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. $60.00 $120.56 99245 Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family. $80.00 $151.44 Vision Services Procedure Code Description Current Fee MA Fee Effective July 1, 2008 92002 Ophthalmological services: medical examination and evalu- ation with initiation of diagnostic and treatment program; intermediate, new patient $17.00 $28.34 92004 Ophthalmological services: medical examination and evalu- ation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits $17.00 $58.77 92012 Ophthalmological services: medical examination and evalu- ation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient $17.00 $29.41 92014 Ophthalmological services: medical examination and evalu- ation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits $17.00 $45.28 Dental Services Procedure Code Description Current Fee MA Fee Effective July 1, 2008 D2140 Amalgam--one surface, primary or permanent $40.00 $45.00 D2150 Amalgam--two surfaces, primary or permanent $50.00 $55.00 D2160 Amalgam--three surfaces, primary or permanent $60.00 $65.00 D2161 Amalgam--four or more surfaces, primary or permanent $60.00 $65.00 D2330 Resin-based composite--one surface, anterior $45.00 $50.00 D2331 Resin-based composite--two surfaces, anterior $55.00 $60.00 D2332 Resin-based composite--three surfaces, anterior $60.00 $65.00 D2335 Resin-based composite--four or more surfaces or involving incisal angle (anterior) $60.00 $65.00 D2390 Resin-based composite crown, anterior $145.00 $150.00 D2391 Resin-based composite--one surface, posterior $45.00 $50.00 D2392 Resin-based composite--two surfaces, posterior $55.00 $60.00 D2393 Resin-based composite--three surfaces, posterior $60.00 $65.00 D2394 Resin-based composite--four or more surfaces, posterior $60.00 $65.00 D2740 Crown--porcelain/ceramic substrate $350.00 $500.00 D2751 Crown--porcelain fused to predominantly base metal $350.00 $500.00 D2791 Crown--full cast predominantly base metal $350.00 $475.00 D2934 Prefabricated esthetic coated stainless steel crown-- primary tooth $99.00 $145.00 D2952 Cast post and core in addition to crown $75.00 $80.00 D2954 Prefabricated post and core in addition to crown $75.00 $80.00 D3220 Therapeutic pulpotomy (excluding final restoration)-- removal of pulp coronal to the dentinocemental junction and application of medicament $57.00 $75.00 D3310 Anterior (excluding final restoration) $210.00 $275.00 D3320 Bicuspid (excluding final restoration) $270.00 $375.00 D3330 Molar (excluding final restoration) $345.00 $500.00 D5110 Complete denture--maxillary $355.00 $525.00 D5120 Complete denture--mandibular $355.00 $525.00 D5130 Immediate denture--maxillary $355.00 $525.00 D5140 Immediate denture--mandibular $355.00 $525.00 D5211 Maxillary partial denture--resin base (including any con- ventional clasps, rests and teeth) $250.00 $375.00 D5212 Mandibular partial denture--resin base (including any conventional clasps, rests and teeth) $250.00 $375.00 D5213 Maxillary partial denture--cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $370.00 $550.00 D5214 Mandibular partial denture--cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $370.00 $550.00 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $60.00 $65.00 D7210 Surgical removal of erupted tooth requiring elevation of mucoperitoseal flap and removal of bone and/or section of tooth $60.00 $65.00 D7220 Removal of impacted tooth--soft tissue $65.00 $90.00 D7230 Removal of impacted tooth--partially bony $120.00 $170.00 D7240 Removal of impacted tooth--completely bony $140.00 $200.00 D7250 Surgical removal of residual tooth roots (cutting procedure) $60.00 $100.00 D8080 Comprehensive orthodontic treatment of the adolescent dentition (includes initial periodic treatment) $600.00 $1,000.00 D8670 Periodic orthodontic treatment (as part of contract) $250.00 $350.00 Private Duty (Shift) Nursing Services Procedure Code Description Current Fee MA Fee Effective July 1, 2008 S9123 Nursing care, in the home, by Registered Nurse, per hour $35.00 $40.00 S9124 Nursing care, in the home, by Licensed Practical Nurse, per hour $35.00 $40.00 Home Health Agency Services Procedure Code Description Current Fee MA Fee Effective July 1, 2008 99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, nonstress test, uterine monitoring and gestational diabetes monitoring $77.00 $88.00 99501 Home visit for postnatal assessment and follow-up care $77.00 $88.00 G0151 Services of physical therapist in home health setting $77.00 $88.00 G0152 Services of occupational therapist in home health setting $77.00 $88.00 G0153 Services of speech and language pathologist in home health setting $77.00 $88.00 G0154 Services of skilled nurse in home health setting $77.00 $88.00 G0156 Services of home health aide in home health setting $40.00 $46.00 Family Planning Clinic Visits Procedure Code Description Current Fee MA Fee Effective July 1, 2008 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. $20.00 $35.33 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. $20.00 $54.25 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. $20.00 $35.00 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. $20.00 $54.42 Healthy Beginnings Plus Services Procedure Code Description Current Fee MA Fee Effective July 1, 2008 99203 Second Trimester Basic Maternity Care Visit $40.00 $54.25 99204 Second Trimester High Risk Maternity Care Visit $40.00 $90.37 99205 Third Trimester Basic Maternity Care Visit $40.00 $117.54 99205 Third Trimester High Risk Maternity Care Visit $40.00 $117.54 99214 Second Trimester High Risk Maternity Care Visit $40.00 $54.42 99215 Third Trimester Basic Maternity Care Visit $40.00 $78.05 99215 Third Trimester High Risk Maternity Care Visit $40.00 $78.05 99384 First Trimester Basic Maternity Care Package $121.00 $221.00 99384 First Trimester High Risk Maternity Care Package $159.00 $259.00 99384 Second Trimester Basic Maternity Care Package $183.00 $283.00 99384 Second Trimester High Risk Maternity Care Package $297.00 $397.00 99385 First Trimester Basic Maternity Care Package $121.00 $221.00 99385 First Trimester High Risk Maternity Care Package $159.00 $259.00 99385 Second Trimester Basic Maternity Care Package $183.00 $283.00 99385 Second Trimester High Risk Maternity Care Package $297.00 $397.00 99386 First Trimester Basic Maternity Care Package $121.00 $221.00 99386 First Trimester High Risk Maternity Care Package $159.00 $259.00 99386 Second Trimester Basic Maternity Care Package $183.00 $283.00 99386 Second Trimester High Risk Maternity Care Package $297.00 $397.00 99394 First Trimester Basic Maternity Care Package $121.00 $221.00 99394 First Trimester High Risk Maternity Care Package $159.00 $259.00 99394 Second Trimester Basic Maternity Care Package $183.00 $283.00 99394 Second Trimester High Risk Maternity Care Package $297.00 $397.00 99395 First Trimester Basic Maternity Care Package $121.00 $221.00 99395 First Trimester High Risk Maternity Care Package $159.00 $259.00 99395 Second Trimester Basic Maternity Care Package $183.00 $283.00 99395 Second Trimester High Risk Maternity Care Package $297.00 $397.00 99396 First Trimester Basic Maternity Care Package $121.00 $221.00 99396 First Trimester High Risk Maternity Care Package $159.00 $259.00 99396 Second Trimester Basic Maternity Care Package $183.00 $283.00 99396 Second Trimester High Risk Maternity Care Package $297.00 $397.00 99429 Outreach Bonus for First Trimester Recruitment $100.00 $200.00 H1002 Outreach Visit $45.00 $100.00 Additions to Fee Schedule
The Department has added the following procedure codes to the Fee Schedule:
Laboratory Service Procedure Code Description MA Fee 81007 Urinalysis; bacteriuria screen, except by culture or dipstick $3.00 Screening for Developmental Delays and Autism Spectrum Disorder Procedure Code Description MA Fee 96110 Developmental testing, limited (such as, Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report, each 15 minutes $11.00 The Department has issued MA Bulletins to affected providers with instructions for billing the procedure codes specified previously.
Fiscal Impact
These changes are expected to result in increased costs of $ 15.279 million ($7.138 million in State funds) in the MA Outpatient Program in Fiscal Year (FY) 2008-2009 and projected costs of $18.335 million ($8.544 million in State funds) in FY 2009-2010.
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 revision 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 at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-NOT-566. (1) General Fund; (2) Implementing year 2008-09 is $7.138 million; (3) 1st Succeeding Year 2009-10 is $8.544 million; 2nd Succeeding Year 2010-11 $8.544 million; 3rd Succeeding Year is $8.544 million; 4th Succeeding Year 2012-13 is $8.544 million; 5th Succeed Year 2013-14 is $8.544 million; (4) 2007-08 Program $593.992 million; 2006-07 Program $671.472 million; 2005-06 Program $945.950 million; (7) Medical Assistance--Outpatient; (8) recommends adoption.
[Pa.B. Doc. No. 08-1607. Filed for public inspection August 29, 2008, 9:00 a.m.]
