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PA Bulletin, Doc. No. 04-1613

NOTICES

Medical Assistance Program Fee Schedule Revisions; 2003 HCPCS Updates; Prior Authorization Requirements

[34 Pa.B. 4790]

   By this notice, 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 2003 updates made by the Centers for Medicare and Medicaid Services to the Healthcare Common Procedure Coding System (HCPCS). The 2003 HCPCS codes are effective for dates of service on and after January 1, 2004.

   In addition to the HCPCS updates, the Department is adding procedure code G0234 with effective dates of service on and after July 1, 2004. Procedure code G0234 is being added because the Department has received a significant number of requests for that service through the program exception process authorized by 55 Pa. Code § 1150.63 (relating to waivers).

   Effective with dates of service on and after July 1, 2004, the Department is revising the fees for several existing procedure codes. Specifically, the Department is adjusting the fees for the following existing procedure codes for neonatal and pediatric services so that payment rates for these procedure codes remain consistent with payment rates for the procedure codes added as a result of the HCPCS updates:

99295 Old Fee:   $450 New Fee:   $703.91
99296 Old Fee:   $230 New Fee:   $309.43
99298 Old Fee:     $80 New Fee:   $108.56

   In addition, the Department is reducing the fee for procedure code 58611 to reflect an appropriate payment rate to comply with the State Plan requirement that Pennsylvania Medicaid fees not exceed Medicare reimbursement fees:

58611 (surgeon) Old Fee: $876 New Fee: $74.91
58611 (asst. surgeon) Old Fee: $175.20 New Fee: $14.86

   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.

Prior Authorization Requirements

   The following new HCPCS procedure codes are for items of durable medical equipment that cost more than $100 and therefore are subject to prior authorization under 62 P. S. § 443.6(b)(2):


A7025 High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each
A7030 Full face mask used with positive airway pressure device, each
E0117 Crutch, underarm, articulating, spring assisted, each
E0701 Helmet with face guard and soft interface material, prefabricated
E1012Integrated seating system, planar, for pediatric wheelchair
E1013Integrated seating system, contoured, for pediatric wheelchair
E1014 Reclining back, addition to pediatric wheelchair
E1016 Shock absorber for power wheelchair, each
E1020 ''Residual limb support system for wheelchair''
E1161 Manual adult size wheelchair, includes tilt in space
E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system
E1236 Wheelchair, pediatric size, folding, adjustable, with seating system
E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system
E1238 Wheelchair, pediatric size, folding, adjustable, without seating system
L0450 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panels, includes shoulder straps and closures, prefabricated, includes fitting and adjustment
L0452 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panels, includes shoulder straps and closures, custom fabricated
L0454TLSO flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panels, includes shoulder straps and closures, prefabricated, includes fitting and adjustment
L0456 TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, includes fitting and adjustment
L0458 TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and tranverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
L0460 TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and tranverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
L0462 TLSO, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
L0464TLSO, triplanar control, modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and tranverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
L0466 TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment
L0468 TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment
L0470 TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and tranverse planes, produces intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment
L0472 TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment
L0474 TLSO, triplanar control, rigid posterior frame with flexible soft apron anterior with multiple straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in the sagittal, coronal, and tranverse planes, produces intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment
L0476 TLSO, sagittal-coronal control, flexion compression jacket, two rigid plastic shells with soft liner, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, usually laced together on one side, restricts gross trunk motion in sagittal and coronal planes, allows free flexion and compression of the LS region, includes straps and closures, prefabricated, includes fitting and adjustment
L0478 TLSO, sagittal-coronal control, flexion compression jacket, two rigid plastic shells with soft liner, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, usually laced together on one side, restricts gross trunk motion in sagittal and coronal planes, allows free flexion and compression of LS region, includes straps and closures, custom fabricated
L0480 TLSO, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated
L0482 TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated
L0484 TLSO, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated
L0486 TLSO, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated
L0488 TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment
L0490 TLSO, sagittal-coronal control, one piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment
L1652 Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type
L1836 Knee orthosis, rigid, without joints, includes soft interface material, prefabricated, includes fitting and adjustment
L3652 Shoulder orthosis, double shoulder, elastic, prefabricated, includes fitting and adjustment (for example, neoprene, lycra)
L4386 Non-pneumatic walking splint, with or without joints, prefabricated, includes fitting and adjustment
L5781 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system
L5848 Addition to endoskeletal, knee-shin system, hydraulic stance extension, dampening feature, adjustable
L6025 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device
L6638 Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow
L6646 Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system
L6647 Upper extremity addition, shoulder lock mechanism, body powered actuator
L6648 Upper extremity addition, shoulder lock mechanism, external powered actuator
L7367 Lithium ion battery, replacement
L7368 Lithium ion battery charger

   The following new HCPCS procedure codes are subject to prior authorization, as authorized in 62 P. S. § 443.6(b)(7):

G0234 Positive emission tomography, regional or whole body, for solitary pulmonary nodule following CT or for initial staging of pathologically diagnosed nonsmall cell lung cancer; gamma cameras only
J7342 Dermal tissue, of human origin, with or without other bioengineered or processed elements, with metabolically active elements, per square centimeter

Changes to the MA Program Fee Schedule for Provider Types
01, 02, 03, 07, 08, 12, 15, 18, 25, 26, 29, 31, 33, 34, 47, 59

Procedure Codes Added to the Fee Schedule as a Result of the Updates and Additions which are Effective and Compensable for Dates of Service as of January 1, 2004
 

Procedure CodeModifiersProcedure CodeModifiers Procedure CodeModifiers
A4266A4267A4268
A4281A4282A4283
A4284A4285A4286
A4405A4406A4407
A4408A4409A4410
A4413A4414A4415
A4422A4450A4452
A4525A4526A4527
A4528A4531A4532
A4534A4609A4610
A4633A4930A4931
A4932A6011A6410
A6411A6421A7025
A7026A7030A7031
A7032A7033A7034
A7035A7036A7037
A7038A7039A7044
B4100E0117NU E0454RR
E0461RR E0483RR E0484NU
E0618RR E0636RR E0701NU
E1012NU, RR E1013NU, RR E1014NU, RR
E1015NU, RR E1016NU, RR E1020NU, RR
E1025NU, RR E1026NU, RR E1027NU, RR
E1037RR E1038RR E1161NU, RR
E1232NU, RR E1233NU, RR E1234NU, RR
E1235NU, RR E1236 NU, RR E1237NU, RR
E1238NU, RR E1802RR L0450
L0452L0454L0456
L0458L0460L0462
L0464L0466L0468
L0470L0472L0474
L0476L0478L0480
L0482L0484L0486
L0488L0490L1652
L1836L1901L3651
L3652L3701L3762
L3909L3911L4386
L5781L5848L6025
L6638L6646L6647
L6648L7367L7368
G023426, TC G0269SG G0290SG
G0291SG J73420031TSG
20612 SG 21046SG 21047SG
21048SG 21049SG 2174280, SG
2174380, SG 29827SG 29873SG
29899SG 33215SG 33224 SG
33225SG 33226SG 3350880
3483380 3483480 3490080
3557280 36511SG 36512SG
36513 SG 36514SG 36515SG
36516SG 3718280 3718380
3750080, SG 38205SG 38206 SG
38242 SG 43201SG 43236SG
4420680 44207 80 4420880
44210 80 4421180 4421280
4470180 45335SG 45340SG
45381SG 45386 SG 46706SG
49419SG 49904 80 5054280, SG
5054380, SG 50562SG 51701
5170251703SG 51798
5586680 56820SG 56821 SG
57420SG 57421SG 57455SG
57456SG 57461SG 58146 80, SG
5829080, SG 58291 80 5829280
5829380 5829480 58545 80, SG
5854680, SG 5855280, SG 58553 80, SG
58554 80, SG 6131680 61322 80
6132380 6151780 6162380, SG
62148 80, SG 6216080, SG 62161 80, SG
6216280, SG 62163 80, SG 62164 80, SG
6216580, SG 64416SG 64446 SG
64447SG 64448SG 75901 26, TC
7590226, TC 75954 26 7607126, TC
76801 26, TC 7680226, TC 76811 26, TC
7681226, TC 7681726, TC 83880
843028500485032
850498538087255
872678727188174
881758905592601
926029260392604
926109261192612
926139261492615
926169261793580
935819599096920SG
96921SG 96922SG 99293
9929499299E0951

Procedure Codes deleted from the Fee Schedule as a Result of the Updates which will not be Compensable for Services Provided After August 31, 2004:

Procedure Codes
A4370 G0015 L0310 L0390 L0950 47133 94665
A4374 K0021 L0315 L0391 L0986 58551 99297
A4386 K0034 L0317 L0400 L5660 85021
A4572 K0101 L0320 L0410 L5662 85022
A5123 K0183 L0321 L0420 L5663 85023
A6405 K0184 L0330 L0430 L5664 85024
A6406 K0185 L0331 L0440 21041 85031
E0608 K0186 L0340 L0900 33930 85590
G0004 K0187 L0350 L0910 33940 85595
G0005 K0188 L0360 L0920 36520 87198
G0006 K0189 L0370 L0930 36521 87199
G0007 L0300 L0380 L0940 38231 90709

Fiscal Impact

   The fiscal note was prepared under provision of section 612 of The Administrative code of 1929 (71 P. S. § 232). The estimated cost for Fiscal Year 2003-2004 is $1.287 million ($0.582 million in State funds). The estimated cost for Fiscal Year 2004-2005 is $3.861 million ($1.773 million in State funds).

Public Comment

   Interested persons are invited to submit written comments to this notice within 30 days of this publication 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 will be considered in subsequent revisions to the fee schedule. Persons with a disability may use the AT&T Relay Services, (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).

ESTELLE B. RICHMAN,   
Secretary

   Fiscal Note: 14-NOT-393. (1) General Fund; (2) Implementing Year 2003-04 is $582,000; (3) 1st Succeeding Year 2004-05 is $1,773,000; 2nd Succeeding Year 2005-06 is $1,782,000; 3rd Succeeding Year 2006-07 is $1,782,000; 4th Succeeding Year 2007-08 is $1,782,000; 5th Succeeding Year 2008-09 is $1,782,000; (4) 2002-03 Program--$668,832,000; 2001-02 Program--$705,750,000; 2000-01 Program--$668,586,000; (7) Medical Assistance--Outpatient; (8) recommends adoption. The previous costs have been included in the Fist Supplemental General Appropriation Act of (2003) (Act 9A) and the General Appropriation Act of 2004 (Act 7A).

[Pa.B. Doc. No. 04-1613. Filed for public inspection August 27, 2004, 9:00 a.m.]



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