1683 Medical Assistance program fee schedule revisions; 2005 HCPCS updates; prior authorization requirements

Medical Assistance Program Fee Schedule Revisions; 2005 HCPCS Updates; Prior Authorization Requirements

[35 Pa.B. 5053]

   The Department of Public Welfare (Department) announces several changes to the Medical Assistance (MA) Program Fee Schedule, and accompanying prior authorization requirements.

Fee Schedule Revisions

   The Department is adding and end-dating procedure codes as a result of implementing the 2005 updates made by the Centers for Medicare and Medicaid Services (CMS) to the Healthcare Common Procedure Coding System (HCPCS). The 2005 HCPCS codes are effective for dates of service on and after October 1, 2005.

   In addition to the 2005 HCPCS updates, the Department is adding the following procedure codes effective for dates of service on and after October 1, 2005: D7472, D7473, D7485, D5710, D7520, E2500, E2502, E2504, E2506, E2508, E2510, 17250, 66982, 87621, 93741, 93742, 93743, 93744 and 97602. These codes are being added due to significant Program Exception requests.

   Procedure Code D1110 is currently on the Fee Schedule for recipients 13 years of age and older, however due to a clarification of the definition of adult by the American Dental Association as an individual 12 years of age and older, effective for dates of service on and after October 1, 2005, this code will be compensable for eligible recipients 12 years of age and older.

   Certain procedure codes currently on the Fee Schedule will now be compensable for services provided in an Ambulatory Surgical Center (ASC) and Short Procedure Unit (SPU). ASCs and SPUs may bill for the following procedure codes using an SG modifier effective for dates of service on and after October 1, 2005: 31623, 31624, 31631, 31643, and 31646.

   Fees for the added procedure codes will be published in a Medical Assistance Bulletin that will be issued to all providers within a few weeks.

   Some local procedure codes that are being end-dated are being replaced with National procedure codes. In some instances, the fee associated with the National procedure code is higher or lower than the fee associated with the local procedure code. If the fee has been reduced, it is to reflect an appropriate payment rate to comply with the State Plan requirement that Pennsylvania Medicaid fees not exceed Medicare reimbursement fees. Specific information about these fee changes can be found in the table in this notice.

Prior Authorization Requirements

   The following 2005 HCPCS procedure codes for items of durable medical equipment require prior authorization under section 443.6(b)(2) of the Public Welfare Code (code) (62 P. S. § 443.6(b)(2)), as amended by the act of July 7, 2005 (P. L. 177, No. 42), either because the item costs more than $600, or because the item costs $600 or less and the Department has determined to require prior authorization:

   E1039 NU Transport chair, adult size, heavy duty, patient weight capacity 250 pounds or greater.

   E2291 NU Back, planar, for pediatric size wheelchair including fixed attaching hardware.

   E2292 NU Seat, planar, for pediatric size wheelchair including fixed attaching hardware.

   E2293 NU Back, contoured, for pediatric size wheelchair including fixed attaching hardware.

   E2294 NU Seat, contoured, for pediatric size wheelchair including fixed attaching hardware.

   E2368 NU Power wheelchair component, motor, replacement only.

   E2369 NU Power wheelchair component, gear box, replacement only.

   E2370 NU Power wheelchair component, motor and gear box combination, replacement only.

   E2602 NU General use wheelchair seat cushion, width 22 in. or greater, any depth.

   E2603 NU Skin protection wheelchair seat cushion, width less than 22 in., any depth.

   E2604 NU Skin protection wheelchair seat cushion, width 22 in. or greater, any depth.

   E2605 NU Positioning wheelchair seat cushion, width less than 22 in., any depth.

   E2606 NU Positioning wheelchair seat cushion, width 22 in. or greater, any depth.

   E2607 NU Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth.

   E2608 NU Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth.

   E2611 NU General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware.

   E2612 NU General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware.

   E2613 NU Positioning wheelchair back cushion, posterior, width less than 22 inches, any height, including any type mounting hardware.

   E2614 NU Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height, including any type mounting hardware.

   E2615 NU Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height, including any type mounting hardware.

   E2616 NU Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height, including any type mounting hardware.

   E2618 NU Wheelchair accessory, solid seat support base (replaces sling seat), for use with manual wheelchair or lightweight power wheelchair, includes any type mounting hardware.

   E2620 NU Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches, any height, including any type mounting hardware.

   E2621 NU Positioning wheelchair back cushion, planar back with lateral supports, width 22 inches or greater, any height, including any type mounting hardware.

   The following 2005 HCPCS procedure codes are for orthoses and are therefore subject to prior authorization under section 443.6(b)(1) of the code:

   K0630 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment.

   K0631 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated.

   K0634 Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment.

   K0635 Lumbar orthosis, sagittal control, with rigid posterior panels, posterior extends from L-1 to below L-5 vertebrae, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment.

   K0636 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment.

   K0637 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment.

   K0639 Lumbar-sacral orthosis, sagittal control, with rigid posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment.

   K0640 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment.

   K0645 Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated.

   K0646 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment.

   K0647 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated.

   K0648 Lumbar-sacral orthosis, sagittal-coronal control, rigid shells/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid plastic and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment.

   K0649 Lumbar-sacral orthosis, sagittal-coronal control, rigid shells/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid plastic and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated.

   L1932 RT, LT, 50 AFO, rigid anterior tibial section, total Carbon fiber or equal material, prefabricated, includes fitting and adjustment.

   L8615 Headset/headpiece for Use with cochlear implant device, replacement.

   The following 2005 HCPCS procedure codes are for orthopedic shoes and other supportive foot devices and therefore are subject to prior authorization under section 443.6(b)(6) of the code:

   K0628 RT, LT, 50 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230°F or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 (or higher), prefabricated, each.

   K0629 RT, LT, 50 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping material, custom fabricated, each.

   The following 2005 HCPCS procedure codes are subject to prior authorization as authorized under section 443.6(b)(7) of the code:

   79005 Radiopharmaceutical therapy, by oral administration.

   79101 Radiopharmaceutical therapy, by intravenous administration.

   79445 Radiopharmaceutical therapy, by intra-arterial particulate administration.

   B4157 BO Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (over 21 years of age).

   The following HCPCS procedure codes being added in addition to the 2005 HCPCS updates are for items of durable medical equipment and require prior authorization under section 443.6(b)(2) of the code either because the item costs more than $600, or because the item costs $600 or less and the Department has determined to require prior authorization:

   E2500 NU Speech generating device, digitized speech, using prerecorded messages, less than or equal to 8 minutes recording time.

   E2502 NU Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time.

   E2504 NU Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time.

   E2506 NU Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time.

   E2508 NU Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device.

   E2510 NU Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access.

PROCEDURE CODES BEING ADDED TO THE MA PROGRAM FEE SCHEDULE AS A RESULT OF THE 2005 HCPCS UPDATES WHICH ARE EFFECTIVE AND COMPENSABLE FOR DATES OF SERVICE AS OF OCTOBER 1, 2005

Procedure Code And Modifiers	Procedure Code And Modifiers	Procedure Code And Modifiers	Procedure Code And Modifiers
A4349	A4605	A4705	A7527
B4103	B4157 BO	B4158 BO	B4159 BO
B4160 BO	B4161 BO	B4162 BO	D2915 SG
D2934 SG	D7283 SG	D7288 SG	D7511 SG
D7521 SG	E1039 NU, RR	E2205 NU, RR	E2206 NU, RR
E2291 NU	E2292 NU	E2293 NU	E2294 NU
E2368 NU, RR	E2369 NU, RR	E2370 NU, RR	E2601 NU, RR
E2602 NU, RR	E2603 NU, RR	E2604 NU, RR	E2605 NU, RR
E1606 NU, RR	E2607 NU, RR	E2608 NU, RR	E2611 NU, RR
E2612 NU, RR	E2613 NU, RR	E2614 NU, RR	E2615 NU, RR
E2616 NU	E2618 NU	E2619 NU, RR	E2620 NU, RR
E2621 NU	G0356	G0363	G0364
G0365 26, TC	K0628 RT, LT, 50	K0629 RT, LT, 50	K0630
K0631	K0634	K0635	K0636
K0637	K0639	K0640	K0642
K0644	K0645	K0646	K0647
K0648	K0649	K0671 RR	L1932 RT, LT, 50
L8515	L8615	L8616	L8617
L8618	L8620	L8621	L8622
S0618	T4521	T4522	T4523
T4524	T4525	T4526	T4527
T4528	T4529	T4530	T4531
T4532	T4533	T4534	T4535
T4536	T4537	T4540	T4541
T4542	00561	11004 SG	11005 SG
11006 SG	11008	19296 RT, LT, 50, SG	19297 RT, LT, 50
19298 SG, RT, LT, 50	29867 SG, 80, RT, LT	31545 SG	31546 SG
31620	31636 SG	31637	31638 SG
32019 SG, RT, LT, 50	34803 80	36818 SG, RT, LT, 50	37215 RT, LT, 50
37216 RT, LT, 50	44137 80	45391 SG	45392 SG
46947 SG	50391 SG, RT, LT, 50	52402 SG	57267 SG, 80
57283 SG, 80	58356 SG	58565 SG, 80	58956 80
63050 SG, 80	63051 SG, 80	63295 80	66711 SG, RT, LT, 50
76077 26, TC	76510 26, TC, RT, LT, 50	76820 26, TC	76821 26, TC
78811 26	78812 26	78813 26	78814 26
78815 26	78816 26	79005 26, TC	79101 26, TC
79445 26, TC	82045	82656	83009
83630	84163	84166	86064
86335	86379	86587	87807
88184	88185	88187	88188
88189	88360 26, TC	88367 26, TC	88368 26, TC
90656	91034 26, TC	91035 26, TC	91037 26, TC
91038 26, TC	91040 26, TC, SG	91120 26, TC	92620
92621	92625 52	93890 26,TC	93892 26, TC
93893 26, TC	95928 26, TC	95929 26, TC	95978 SG
95979	97597 SG	97598	97605
97606

NATIONAL PROCEDURE CODES BEING ADDED BY THE DEPARTMENT TO THE MA PROGRAM FEE SCHEDULE AS A RESULT OF SIGNIFICANT PROGRAM EXCEPTION REQUESTS WHICH ARE EFFECTIVE AND COMPENSABLE FOR DATES OF SERVICE AS OF OCTOBER 1, 2005

Procedure Code And Modifiers	Procedure Code And Modifiers	Procedure Code And Modifiers	Procedure Code And Modifiers
D7472	D7473	D7485	D7510
D7520	E2500 NU, RR	E2502 NU, RR	E2504 NU, RR
E2506 NU, RR	E2508 NU, RR	E2510 NU, RR	17250
66982	87621	93741 26, TC	93742 26, TC
93743 26, TC	93744 26, TC	97602 26, TC

NATIONAL PROCEDURE CODES BEING END-DATED FROM THE MA PROGRAM FEE SCHEDULE AS A RESULT OF THE 2005 HCPCS UPDATES AND WHICH WILL NOT BE COMPENSABLE FOR SERVICES PROVIDED AFTER SEPTEMBER 30, 2005

Procedure Codes
A4324	A4325	A4347	A4525	A4526	A4527	A4528	A4531
A4532	A4609	A4610	B4151	B4156	E0176	E0177	E0178
E0179	E0192	E0454	E0962	E0963	E0964	E0965	E1012
E1013	K0023	K0024	K0059	K0060	K0061	K0081	K0114
K0115	K0016	L0476	L0478	L0500	L0510	L0515	L0520
L0530	L0540	L0550	L0560	L0561	L0565	L0600	L0610
L2435	L5674	L5675	L5846	35161	35162	35582	50559
78990	79000	79001	79020	79030	79035	79100	79400
79420	79900	88180	91032	91033	92589

LOCAL PROCEDURE CODES BEING END-DATED FROM THE FEE SCHEDULE AS A RESULT OF THE 2005 HCPCS UPDATES AND WHICH WILL NOT BE COMPENSABLE FOR SERVICES PROVIDED AFTER SEPTEMBER 30, 2005

Procedure Codes
Y9895	Z0991	Z0992	Z0993	Z4614	Z4629	Z4630	Z4631
Z4632	Z4633	Z4634	Z4635	Z4636	Z4638	Z4639	Z4640
Z4641	Z9808	W6068	W6070	79898

NATIONAL PROCEDURE CODES PREVIOUSLY END-DATED BY CMS WHICH WILL NOT BE COMPENSABLE FOR SERVICES AFTER SEPTEMBER 30, 2005

Procedure Codes
E1404	85095	85102	93737	93738

LOCAL PROCEDURE CODES BEING END-DATED AND REPLACED WITH NATIONAL PROCEDURE CODES AS A RESULT OF THE 2005 HCPCS UPDATES

End-Date September 30, 2005		Use October 1, 2005		End-Date September 30, 2005		Use October 1, 2005
Y9895	$3.75	A4605	$13.12	Z0991	$68.00	E1225	$407.60
Z0991	$68.00	E1226	$407.60	Z0992	$110.00	E2618	$110.00
Z0993	$110.00	E2291	$405.64	Z0993	$110.00	E2611	$312.35
Z0993	$110.00	E2612	$422.56	Z4614	$12.00	E0190	$31.00
Z4629	$.55	T4525	$.63	Z4629	$.55	T4526	$.65
Z4629	$.55	T4527	$.72	Z4629	$.55	T4528	$.72
Z4629	$.55	T4531	$.55	Z4629	$.55	T4532	$.55
Z4630	$13.00	T4536	$13.00	Z4631	$4.35	T4540	$10.85
Z4632	$.18	T4535	$.76	Z4633	$.47	T4535	$.76
Z4634	$10.85	T4537	$10.85	Z4635	$.19	T4542	$.19
Z4636	$.38	T4541	$.38	Z4638	$.19	T4521	$.63
Z4638	$.19	T4529	$.55	Z4639	$.25	T4522	$.65
Z4639	$.25	T4529	$.55	Z4640	$.37	T4523	$.72
Z4640	$.37	T4530	$.55	Z4641	$.42	T4524	$.72
Z9808	$435.00	E2611	$312.35*	Z9808	$435.00	E2612	$422.56*
*The Department is reducing the fee for this procedure code to reflect an appropriate payment rate to comply with the State Plan requirement that Pennsylvania Medicaid fees not exceed Medicare reimbursement fees.

Fiscal Impact

   The estimated cost for Fiscal Year (FY) 2005-2006 is $1.323 million ($0.595 million in State funds). The estimated cost for FY 2006-2007 is $2.268 million ($1.029 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 Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered in subsequent revisions of this notice.

   Persons with a disability who require an auxiliary aid or service may submit comments using the AT&T Relay Services by calling [phone] (TDD users) or [phone] (voice users).

ESTELLE B. RICHMAN,   
Secretary

   Fiscal Note: 14-NOT-441. (1) General Fund; (2) Implementing Year 2005-06 is $595,000; (3) 1st Succeeding Year 2006-07 is $1,029,000; 2nd Succeeding Year 2007-08 is $1,032,000; 3rd Succeeding Year 2008-09 is $1,032,000; 4th Succeeding Year 2009-10 is $1,032,000; 5th Succeeding Year 2010-11 is $1,032,000; (4) 2004-05 Program--$842.991 million; 2003-04 Program--$727.979 million; 2002-03 Program--$666.832 million; (7) Medical Assistance--Outpatient; (8) recommends adoption. Funds have been included in the Department's budget to cover this increase.

[Pa.B. Doc. No. 05-1683. Filed for public inspection September 9, 2005, 9:00 a.m.]