NOTICES

DEPARTMENT OF HUMAN SERVICES

Medical Assistance Program Fee Schedule Revisions; 2017 Healthcare Common Procedure Coding System Updates; Prior Authorization Requirements

[47 Pa.B. 4595]
[Saturday, August 5, 2017]

 The Department of Human Services (Department) announces changes to the Medical Assistance (MA) Program Fee Schedule. These changes are effective for dates of service on and after August 7, 2017.

 The Department is adding and end-dating procedure codes as a result of implementing the 2017 updates made by the Centers for Medicare & Medicaid Services (CMS) to the Healthcare Common Procedure Coding System (HCPCS). The Department is also adding and end-dating other procedure codes and making changes to procedure codes currently on the MA Program Fee Schedule. As follows, some of the procedure codes being added to the MA Program Fee Schedule will require prior authorization. Fees for the new procedure codes will be published in an MA Bulletin that will be issued to all providers.

Procedure Codes Being Added or End-dated

 The Department is adding the following procedure code and modifier combinations to the MA Program Fee Schedule as a result of the 2017 HCPCS updates:

Procedure Codes and Modifiers
27197	27197 (SG)	27198	27198 (SG)	28291 (SG)
28291 (RT)	28291 (LT)	28291 (50)	28291 (80) (RT)	28291 (80) (LT)
28291 (80) (50)	28295 (SG)	28295 (RT)	28295 (LT)	28295 (50)
28295 (80) (RT)	28295 (80) (LT)	28295 (80) (50)	31551	31551 (SG)
31552	31552 (SG)	31553	31553 (SG)	31554
31554 (SG)	31572 (SG)	31572 (RT)	31572 (LT)	31572 (50)
31573 (SG)	31573 (RT)	31573 (LT)	31573 (50)	31574 (SG)
31574 (RT)	31574 (LT)	31574 (50)	31591	31591 (SG)
31592	33390	33390 (80)	33391	33391 (80)
36456	36901	36901 (SG)	36902	36902 (SG)
36903	36903 (SG)	36904	36904 (SG)	36905
36905 (SG)	36906	36906 (SG)	36907	36908
36909	37246	37246 (SG)	37247	37248
37248 (SG)	37249	62320	62320 (SG)	62321
62321 (SG)	62322	62322 (SG)	62323	62323 (SG)
62324	62324 (SG)	62325	62325 (SG)	62326
62326 (SG)	62327	62327 (SG)	76706	76706 (TC)
76706 (26)	77065	77065 (TC)	77065 (26)	77066
77066 (TC)	77066 (26)	77067	77067 (TC)	77067 (26)
80305	80305 (QW)	80306	80307	81413
81414	84410	84410 (FP)	90682	92242
92242 (TC)	92242 (26)	96160	96160 (FP)	96377
97161 (U8)	97162 (U8)	97163 (U8)	97164	97165 (U8)
97166 (U8)	97167 (U8)	97168	99151	99152
99152 (FP)	99153	99153 (FP)	99155	99156
99156 (FP)	99157	99157 (FP)	A4224	A4225
A4553	G0499	G0499 (FP)	G0659	L1851 (RT)
L1851 (LT)	L1851 (50)	L1852 (RT)	L1852 (LT)	L1852 (50)

 The Department is adding the following procedure code and modifier combinations to the MA Program Fee Schedule based upon provider requests or clinical review:

Procedure Codes and Modifiers
44203	44203 (80)	44205	44205 (80)	81512
90625	T2101

 The Department is end-dating the following procedure codes from the MA Program Fee Schedule as a result of the 2017 HCPCS updates:

Procedure Codes
11752	21495	22305	27193	27194	28290
28293	28294	31582	31588	33400	33401
33403	35450	35458	35471	35472	35475
35476	36147	36148	36870	62310	62311
62318	62319	75791	75962	75964	75966
75968	75978	77051	77052	77055	77056
77057	80300	80301	80302	80303	80304
81280	81281	81282	92140	93965	97001
97002	97003	97004	B9000	G0437	G0477
G0478	G0479	K0901	K0902	S8032

 No new authorizations will be issued for the procedure codes being end-dated on and after August 7, 2017. For any of the previously listed procedure codes that had a prior authorization issued before August 7, 2017, providers should submit claims using the end-dated procedure code, as set forth in the authorization issued by the Department. The Department will accept claims with the end-dated procedure codes until August 7, 2018, for those services that were previously prior authorized.

Prior Authorization Requirements

 The following laboratory procedure codes being added to the MA Program Fee Schedule will require prior authorization, as authorized under section 443.6(b)(7) of the Human Services Code (code) (62 P.S. § 443.6(b)(7)), and as described in the MA Provider Handbook which may be viewed online at http://www.dhs.pa.gov/publications/forproviders/promiseproviderhandbooksandbillingguides/index.htm#.VxaJ1E32ZtQ.

Procedure Codes
81413	81414	81512

 The Department will require prior authorization of procedure code T2101 for pasteurized donor human milk being added to the MA Program Fee Schedule, as authorized under section 443.6(b)(7) of the code.

 The following orthoses procedure code and modifier combinations being added to the MA Program Fee Schedule will require prior authorization, as authorized under section 443.6(b)(1) of the code:

Procedure Codes
L1851 (RT)	L1851 (LT)	L1851 (50)
L1852 (RT)	L1852 (LT)	L1852 (50)

 Updates to Procedure Codes Currently on the MA Program Fee Schedule

Modifier Updates

QW Modifier

 The Department is adding the QW (Clinical Laboratory Improvement Amendments (CLIA) waived test) informational modifier and QW with the Family Planning (FP) modifier, when applicable, to the following procedure codes and the Provider Type (PT)/Specialty (Spec)/Place of Service (POS) combinations on the MA Program Fee Schedule for laboratory tests that CMS identifies as CLIA waived tests. This information is described in MA Bulletin 01-12-67, Clinical Laboratory Improvement Amendments Requirements, which may be viewed online at http://www.dhs.pa.gov/publications/bulletinsearch/bulletinselected/index.htm?bn=01-12-67#.VxaDYE32ZtQ.

Procedure Code	PT/Spec/POS	Modifiers
87633	01/016/23 (emergency room arrangement 1)	QW
	01/017/23 (emergency room arrangement 2)	QW
	01/183/22 (outpatient hospital clinic)	QW
	28/280/81 (independent laboratory)	QW
G0472	01/183/22	QW; QW FP
	28/280/81	QW; QW FP

 The Department is also adding the PT/Spec/POS and modifiers, as indicated, to the following laboratory procedure codes on the MA Program Fee Schedule as a result of the latest tests listed by CMS as CLIA waived tests.

Procedure Code	PT/Spec/POS	Modifier
86803	08/082/49 (independent medical/surgical clinic)	No modifier; QW; FP; QW FP
	08/083/22 (outpatient family planning clinic)	FP; QW FP
	08/083/49 (independent family planning clinic)	FP; QW FP
	09/All/11 (certified registered nurse practitioner)	No modifier; QW; FP; QW FP
	31/All/11 (physician)	No modifier; QW; FP; QW FP
	33/335/11 (certified nurse midwife)	No modifier; QW; FP; QW FP
87633	08/082/49	No modifier; QW
	09/All/11	No modifier; QW
	31/All/11	No modifier; QW
	33/335/11	No modifier; QW
G0472	08/082/49	No modifier; QW; FP; QW FP
	08/083/22	FP; QW FP
	08/083/49	FP; QW FP
	09/All/11	No modifier; QW; FP; QW FP
	31/All/11	No modifier; QW; FP; QW FP
	33/335/11	No modifier; QW; FP; QW FP

Open Places of Service

 The Department is opening POS 22 (outpatient hospital) for the following procedure codes and PT/Spec combinations, as indicated, as the Department has determined that these settings are appropriate for the performance of these services:

Procedure Code	PT/Spec	POS
99241	14/140 (podiatrist) 31/All	22
99242	14/140 31/All	22
99243	14/140 31/All	22
99244	14/140 31/All	22
99245	14/140 31/All	22

End-Date Places of Service

 The Department is end-dating POS 21 (inpatient hospital) for the following procedure codes and PT/Spec combination 27 (Dentist)/All because the service is performed only in the outpatient setting:

Procedure Codes
99241	99242	99243	99244	99245

Service Limits

 The MA Program has established service limits for some of these procedure codes. When a provider determines that a MA beneficiary is in need of a service or item in excess of the established limits, the provider may request a waiver of the limits through the 1150 Administrative Waiver (Program Exception) process. For instructions on how to apply for a Program Exception, refer to the provider handbook at http://www.dhs.pa.gov/publications/forproviders/promiseproviderhandbooksandbillingguides/index.htm#.Vyj_vk32ZtR.

Managed Care Delivery System

 MA Managed Care Organizations (MCO) are not required to impose the service limits that apply in the MA Fee-for Service (FFS) delivery system, although they are permitted to do so. MA MCOs may not impose service limits that are more restrictive than the service limits established in the MA FFS delivery system. An MA MCO that chooses to establish service limits must notify their network providers and members of the limits before implementing the limits.

Fiscal Impact

 The estimated cost for Fiscal Year 2017-2018 is $0.522 million ($0.252 million in State funds). The estimated cost for Fiscal Year 2018-2019 is $0.696 million ($0.335 million in State funds).

Public Comment

 Interested persons are invited to submit written comments regarding this notice to the Department of Human Services, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, Attention: Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received will be reviewed and considered for any subsequent revisions to the MA Program Fee Schedule.

 Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).

THEODORE DALLAS, 
Secretary

 Fiscal Note: 14-NOT-1169. (1) General Fund; (2) Implementing Year 2017-18 is $252,000; (3) 1st Succeeding Year 2018-19 through 5th Succeeding Year 2022-23 are $335,000; (4) 2016-17 Program—$450,970,000; 2015-16 Program—$392,918,000; 2014-15 Program—$564,772,000; (7) MA—FFS; (8) recommends adoption. Funds have been included in the budget to cover this increase.

[Pa.B. Doc. No. 17-1308. Filed for public inspection August 4, 2017, 9:00 a.m.]

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