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DEPARTMENT OF HUMAN SERVICES

Medical Assistance Program Fee Schedule Revisions; 2015 Healthcare Common Procedure Coding System Updates; Prior Authorization Requirements

[45 Pa.B. 5469]
[Saturday, August 29, 2015]

 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 September 1, 2015.

 The Department is adding and end-dating procedure codes as a result of implementing the 2015 updates made by the Centers for Medicare and 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 following procedure codes are being added to the MA Program Fee Schedule as a result of the 2015 HCPCS updates:

Procedure Codes and Modifiers
20604 20604 (SG) 20606 20606 (SG) 20611
20611 (SG) 22510 22510 (SG) 22511 22511 (SG)
22512 22513 22513 (SG) 22514 22514 (SG)
22515 33946 33947 33948 33949
33951 33952 33953 33954 33955
33956 33957 33958 33959 33962
33963 33964 33965 33966 33969
33984 33985 33986 33987 33988
33989 37218 (RT) 37218 (LT) 37218 (50) 43180
43180 (SG) 44381 44381 (SG) 44384 44384 (SG)
44401 44401 (SG) 44402 44402 (SG) 44403
44403 (SG) 44404 44404 (SG) 44405 44405 (SG)
44406 44406 (SG) 44407 44407 (SG) 44408
44408 (SG) 45346 45346 (SG) 45347 45347 (SG)
45349 45349 (SG) 45350 45350 (SG) 45388
45388 (SG) 45389 45389 (SG) 45390 45390 (SG)
45393 45393 (SG) 45398 45398 (SG) 47383
47383 (SG) 62302 62302 (SG) 62303 62303 (SG)
62304 62304 (SG) 62305 62305 (SG) 64486
64487 64488 64489 66179 (SG) 66179 (RT)
66179 (LT) 66179 (50) 66179 (80) (RT) 66179 (80) (LT) 66179 (80) (50)
66184 (SG) 66184 (RT) 66184 (LT) 66184 (50) 66184 (80) (RT)
66184 (80) (LT) 66184 (80) (50) 76641 (RT) 76641 (LT) 76641 (50)
76641 (TC) (RT) 76641 (TC) (LT) 76641 (TC) (50) 76641 (26) (RT) 76641 (26) (LT)
76641 (26) (50) 76642 (RT) 76642 (LT) 76642 (50) 76642 (TC) (RT)
76642 (TC) (LT) 76642 (TC) (50) 76642 (26) (RT) 76642 (26) (LT) 76642 (26) (50)
77306 77306 (TC) 77306 (26) 77307 77307 (TC)
77307 (26) 77316 77316 (TC) 77316 (26) 77317
77317 (TC) 77317 (26) 77318 77318 (TC) 77318 (26)
77385 77386 77387 77387 (TC) 77387 (26)
80163 80165 80300 80301 80302
80303 80304 80320 80321 80322
80324 80325 80326 80327 80328
80329 80330 80331 80335 80336
80337 80342 80343 80344 80345
80346 80347 80348 80349 80353
80354 80358 80361 80362 80363
80364 80365 80369 80370 80375
81435 81436 81519 83006 87623
87623 (FP) 87624 87624 (FP) 87625 87625 (FP)
87806 87806 (QW) 88341 88341 (TC) 88341 (26)
88344 88344 (TC) 88344 (26) 88364 88364 (TC)
88364 (26) 88366 88366 (TC) 88366 (26) 88369
88369 (TC) 88369 (26) 88373 88373 (TC) 88373 (26)
88374 88374 (TC) 88374 (26) 88377 88377 (TC)
88377 (26) 90620 90621 90630 90651
93355 93355 (78) 96127 99188 A4602
G0277 G0472 G6001 G6001 (TC) G6001 (26)
G6001 (26) (78) G6002 G6002 (TC) G6002 (26) G6003
G6004 G6005 G6006 G6007 G6008
G6009 G6010 G6011 G6012 G6013
G6014 G6015 G6016 G6018 G6018 (SG)
G6019 G6019 (SG) G6020 G6020 (SG) G6022
G6022 (SG) G6023 G6023 (SG) G6024 G6024 (SG)
G6025 G6025 (SG) G6030 G6031 G6032
G6034 G6035 G6036 G6037 G6038
G6039 G6040 G6040 (QW) G6042 G6043
G6044 G6045 G6046 G6047 G6049
G6050 G6051 G6052 G6053 G6054
G6056 G6057 G6058 K0901 (RT) K0901 (LT)
K0901 (50) K0902 (RT) K0902 (LT) K0902 (50) L3981 (RT)
L3981 (LT) L3981 (50) L6026 (RT) L6026 (LT) L6026 (50)
L7259 (RT) L7259 (LT) L7259 (50) S8032 S8032 (TC)
S8032 (26)

 The following procedure codes are being added to the MA Program Fee Schedule based upon provider requests, clinical review or significant program exception requests:

Procedure Codes and Modifiers
19030 (RT) 19030 (LT) 19030 (50) 81235 81261 81262
81263 81264 81310 81504 83992 87521
88312 88312 (TC) 88312 (26) 88313 88313 (TC) 88313 (26)
91110 91110 (TC) 91110 (26) 96119 E0627 (RR) E0627 (NU)
G0166 L4360 (RT) L4360 (LT) L4360 (50) L5986 (RT) L5986 (LT)
L5986 (50)

 The following procedure codes are being end-dated from the MA Program Fee Schedule as a result of the 2015 HCPCS updates:

Procedure Codes
00452 00622 00634 21800 21810 22520
22521 22522 22523 22524 22525 29020
29025 33332 33472 33960 33961 36822
42508 43350 44383 44393 44397 45339
45345 45355 45383 45387 61334 61440
61470 61490 61542 61609 61875 62116
64752 64761 64870 66165 72291 72292
74291 76645 76950 77305 77310 77315
77326 77327 77328 77403 77404 77406
77408 77409 77411 77413 77414 77416
77418 77421 80100 80101 80104 80152
80154 80160 80166 80172 80174 80182
80196 80440 82003 82055 82205 82646
82649 82651 82666 82690 82742 82953
82975 83008 83055 83071 83805 83858
83866 84022 87621 88349 C1300 G0461
G0462 L6025 L7260 L7261

 The following procedure codes are being end-dated from the MA Program Fee Schedule based upon clinical review, but will be available through the 1150 Administrative Waiver (Program Exception) process:

Procedure Codes
77605 77620 88130 88140

 The following procedure codes were determined by clinical review to be experimental and are being end-dated from the MA Program Fee Schedule. Under 55 Pa. Code § 1141.59(12) (relating to noncompensable services) payments will not be made for experimental procedures.

Procedure Codes
87477 87482 87487 95905 95981 95982

 Procedure code E0618, apnea monitor without recording feature, is being end-dated, at the recommendation of providers, as providers are using E0619, apnea monitor, with recording feature, already open on the fee schedule.

 Local procedure code X2061 is being end-dated and replaced by National procedure code G0277:

End-dated Procedure
Code
Description POS Replacement Procedure Code Description POS
X2061 Hospital Special Treatment Room support component; Hyperbaric oxygen treatment 99 G0277 Hyperbaric oxygen under pressure, full body chamber, per 30-minute interval 22

 Procedure code G0461 is being end-dated as a result of the 2015 HCPCS update and replaced by procedure code 88342:

End-dated
Procedure
Code
Description Replacement
Procedure
Code
Description
G0461 Immunohistochemistry or immunocytochemistry, per specimen;
first single or multiplex antibody stain
88342 Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure

 No new authorizations will be issued for the procedure codes being end-dated on and after September 1, 2015. For any of the previous procedure codes that had a prior authorization issued before September 1, 2015, 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 September 1, 2016, for those services that were previously prior authorized.

Prior Authorization Requirements

 The following procedure codes are being added to the MA Program Fee Schedule and will require prior authorization, as authorized under section 443.6(b)(7) of the Public Welfare 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.state.pa.us/publications/forproviders/promiseproviderhandbooksandbillingguides/index.htm.

Procedure Codes and Modifiers
81261 81262 81263 81264 81435 81436
81504 81519 91110 91110 (TC) 91110 (26) G0166
G0277 G6016

 The following procedure codes being added to the MA Program Fee Schedule are prostheses or orthoses and will require prior authorization, as authorized under section 443.6(b)(1) of the Code:

Procedure Codes and Modifiers
K0901 (RT) K0901 (LT) K0901 (50) K0902 (RT) K0902 (LT)
K0902 (50) L3981 (RT) L3981 (LT) L3981 (50) L4360 (RT)
L4360 (LT) L4360 (50) L5986 (RT) L5986 (LT) L5986 (50)
L6026 (RT) L6026 (LT) L6026 (50) L7259 (RT) L7259 (LT)
L7259 (50)

 Procedure code E0627 (NU) is being added to the MA Program Fee Schedule and as durable medical equipment will require prior authorization, as authorized under section 443.6(b)(2) of the Code.

 Rental of procedure code E0627 (RR) is being added to the MA Program Fee Schedule, and requires prior authorization after 3 months of rental as authorized under section 443.6(b)(3) of the Code.

 The following procedure code being added to the MA Program Fee Schedule is considered an advanced radiology service and will require prior authorization as authorized under section 443.6(b)(7) of the Code and as described in MA Bulletin 01-14-42 (Advanced Radiologic Imaging Services) which may be viewed online at http://www.dhs.state.pa.us/cs/groups/webcontent/documents/bulletin_admin/c_123646.pdf:

Procedure Codes and Modifiers
S8032 S8032 (TC) S8032 (26)

Updates to Procedure Codes Currently on the MA Program Fee Schedule

Application of Topical Fluoride Varnish by Physicians and Certified Registered Nurse Practitioners (CRNP)

 Procedure code D1206 will be end-dated for physicians (Provider Type (PT) 31) and CRNPs (PT 09). This code is being replaced by procedure code 99188, which is being added as part of the 2015 HCPCS updates for these provider types.

Physician Services

 Procedure code 99183 will be end-dated for PT/specialty (Spec) combination 31/All in place of service (POS) 22 (outpatient hospital) because this service is not payable to physicians in a clinic setting under MA regulations in 55 Pa. Code § 1221.51 (relating to general payment policy).

Clinic Services

 Procedure code 99183 will be added for PT/Spec 01/183 (Hospital Based Medical Clinic) in POS 22 because the Department has determined that it is appropriate for this provider to perform this service in this setting.

Podiatrist Services

 Procedure code 99183 will have PT/Spec 14/140 (podiatrist) added in POS 21 (inpatient hospital) because the Department has determined that it is appropriate for this provider to perform this service in this setting.

Modifier Updates

Right/Left/50 Modifiers

 The surgical procedure code 27280 will have modifiers right (Rt), left (Lt) and bilateral (50) added because the procedure may be performed laterally or bilaterally. The units will be increased from 1 unit per day to 1-2 units per day to allow for bilateral services.

TC/26/Total Modifiers

 Radiology procedure code 78072 will have the total component (no modifier) and technical component (TC) added with applicable pricing and will continue to require prior authorization. PT/Specs 01/183, 08/082 (Independent Medical/Surgical Clinic) and 31/All, will also be added, as indicated, as a result of adding the Total and TC modifiers:

PT/Spec POS Modifiers Total Pricing TC Pricing
01/183 22 No Modifier, TC $319.38 $258.15
08/082 49 (Independent Clinic) No Modifier, TC
31/All 11 (Office) No Modifier, TC

QW Modifier

 The Department is adding the informational modifier, QW (Clinical Laboratory Improvement Amendments (CLIA) waived test), and QW with the Family Planning (FP) modifier, when applicable, to the following laboratory procedure codes on the MA Program Fee Schedule that are listed with CMS as CLIA waived tests.

Procedure Code PT/Spec/POS Modifiers
86780 01/016/23 (Emergency Room, Arrangement 1)
01/017/23 (Emergency Room, Arrangement 2)
QW
86780 01/183/22 QW; QW FP
86780 08/083/22 (Outpatient Family Planning Clinic),
08/083/49 (Independent Family Planning Clinic)
QW FP
86780 28/280/81 (Independent Laboratory) QW; QW FP
87502 01/016/23, 01/017/23 QW
87502 01/183/22 QW
87502 28/280/81 QW

 The Department is 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 Modifiers
86780 08/082/49 No Modifier; QW; FP; QW FP
86780 09/All/11 No Modifier; QW; FP; QW FP
86780 31/All/11 No Modifier; QW; FP; QW FP
86780 33/335/11 (Certified Nurse Midwife) No Modifier; QW; FP; QW FP
87502 08/082/49 No modifier; QW
87502 09/All/11 No modifier; QW
87502 31/All/11 No modifier; QW
87502 33/335/11 No modifier; QW

End-Date Places of Service

 The following procedure codes will have POS 22, 23, 49 and/or 99 (Special Treatment Room) end-dated because the Department has determined that these settings are not appropriate for the performance of these services:

Procedure Code POS
27280 22, 23, 49, 99
99183 23, 99

Fiscal Impact

 The estimated cost for Fiscal Year 2015-2016 is $0.779 million ($0.374 million in State funds). The estimated cost for Fiscal Year 2016-2017 is $0.935 million ($0.449 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-973. (1) General Fund; (2) Implementing Year 2015-16 is $374,000; (3) 1st Succeeding Year 2016-17 through 5th Succeeding Year 2020-21 are $449,000; (4) 2014-15 Program—$348,741,000; 2013-14 Program—$264,179,000; 2012-13 Program—$450,835,000; (7) MA—Outpatient; (8) recommends adoption. Funds have been included in the budget to cover this increase.

[Pa.B. Doc. No. 15-1593. Filed for public inspection August 28, 2015, 9:00 a.m.]



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