NOTICES
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 ModifiersProcedure Code
And ModifiersProcedure Code
And ModifiersProcedure Code
And ModifiersA4349 A4605 A4705 A7527 B4103 B4157
BOB4158
BOB4159
BOB4160
BOB4161
BOB4162
BOD2915
SGD2934
SGD7283
SGD7288
SGD7511
SGD7521
SGE1039
NU, RRE2205
NU, RRE2206
NU, RRE2291
NUE2292
NUE2293
NUE2294
NUE2368
NU, RRE2369
NU, RRE2370
NU, RRE2601
NU, RRE2602
NU, RRE2603
NU, RRE2604
NU, RRE2605
NU, RRE1606
NU, RRE2607
NU, RRE2608
NU, RRE2611
NU, RRE2612
NU, RRE2613
NU, RRE2614
NU, RRE2615
NU, RRE2616
NUE2618
NUE2619
NU, RRE2620
NU, RRE2621
NUG0356 G0363 G0364 G0365
26, TCK0628
RT, LT, 50K0629
RT, LT, 50K0630 K0631 K0634 K0635 K0636 K0637 K0639 K0640 K0642 K0644 K0645 K0646 K0647 K0648 K0649 K0671
RRL1932
RT, LT, 50L8515 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
SG11005
SG11006
SG11008 19296
RT, LT, 50, SG19297
RT, LT, 5019298
SG, RT, LT, 5029867
SG, 80, RT, LT31545
SG31546
SG31620 31636
SG31637 31638
SG32019
SG, RT, LT, 5034803
8036818
SG, RT, LT, 5037215
RT, LT, 5037216
RT, LT, 5044137
8045391
SG45392
SG46947
SG50391
SG, RT, LT, 5052402
SG57267
SG, 8057283
SG, 8058356
SG58565
SG, 8058956
8063050
SG, 8063051
SG, 8063295
8066711
SG, RT, LT, 5076077
26, TC76510
26, TC, RT, LT, 5076820
26, TC76821
26, TC78811
2678812
2678813
2678814
2678815
2678816
2679005
26, TC79101
26, TC79445
26, TC82045 82656 83009 83630 84163 84166 86064 86335 86379 86587 87807 88184 88185 88187 88188 88189 88360
26, TC88367
26, TC88368
26, TC90656 91034
26, TC91035
26, TC91037
26, TC91038
26, TC91040
26, TC, SG91120
26, TC92620 92621 92625
5293890
26,TC93892
26, TC93893
26, TC95928
26, TC95929
26, TC95978
SG95979 97597
SG97598 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 ModifiersProcedure Code
And ModifiersProcedure Code
And ModifiersProcedure Code
And ModifiersD7472 D7473 D7485 D7510 D7520 E2500
NU, RRE2502
NU, RRE2504
NU, RRE2506
NU, RRE2508
NU, RRE2510
NU, RR17250 66982 87621 93741
26, TC93742
26, TC93743
26, TC93744
26, TC97602
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, 2005Use
October 1, 2005End-Date
September 30, 2005Use
October 1, 2005Y9895 $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 (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
ESTELLE B. RICHMAN,
SecretaryFiscal 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.]
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