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Medical Assistance Program Fee Schedule Revisions; 2016 Healthcare Common Procedure Coding System Updates; Prior Authorization Requirements

[46 Pa.B. 3348]
[Saturday, June 25, 2016]

 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 July 1, 2016.

 The Department is adding and end-dating procedure codes as a result of implementing the 2016 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 following procedure code and modifier combinations are being added to the MA Program Fee Schedule as a result of the 2016 HCPCS updates:

Procedure Codes and Modifiers
10035 10036 31652 31652 (SG) 31653
31653 (SG) 31654 33477 39401 39401 (SG)
39402 39402 (SG) 47531 47531 (SG) 47532
47532 (SG) 47533 47533 (SG) 47534 47534 (SG)
47535 47535 (SG) 47536 47536 (SG) 47537
47537 (SG) 47538 47538 (SG) 47539 47539 (SG)
47540 47540 (SG) 47541 47541 (SG) 47542
47543 47544 50430 (SG) 50430 (RT) 50430 (LT)
50430 (50) 50431 (SG) 50431 (RT) 50431 (LT) 50431 (50)
50432 (SG) 50432 (RT) 50432 (LT) 50432 (50) 50433 (SG)
50433 (RT) 50433 (LT) 50433 (50) 50434 (SG) 50434 (RT)
50434 (LT) 50434 (50) 50435 (SG) 50435 (RT) 50435 (LT)
50435 (50) 50606 (RT) 50606 (LT) 50606 (50) 50693 (SG)
50693 (RT) 50693 (LT) 50693 (50) 50694 (SG) 50694 (RT)
50694 (LT) 50694 (50) 50695 (SG) 50695 (RT) 50695 (LT)
50695 (50) 50705 (RT) 50705 (LT) 50705 (50) 50706 (RT)
50706 (LT) 50706 (50) 54437 54437 (SG) 54437 (80)
54438 54438 (80) 61650 61651 64461
64461 (SG) 64462 64463 65785 (SG) 65785 (RT)
65785 (LT) 65785 (50) 69209 (SG) 69209 (RT) 69209 (LT)
69209 (50) 72081 72081 (TC) 72081 (26) 72082
72082 (TC) 72082 (26) 72083 72083 (TC) 72083 (26)
72084 72084 (TC) 72084 (26) 73501 (RT) 73501 (LT)
73501 (50) 73501 (TC) (RT) 73501 (TC) (LT) 73501 (TC) (50) 73501 (26) (RT)
73501 (26) (LT) 73501 (26) (50) 73502 (RT) 73502 (LT) 73502 (TC) (RT)
73502 (TC) (LT) 73502 (26) (RT) 73502 (26) (LT) 73503 (RT) 73503 (LT)
73503 (TC) (RT) 73503 (TC) (LT) 73503 (26) (RT) 73503 (26) (LT) 73521
73521 (TC) 73521 (26) 73522 73522 (TC) 73522 (26)
73523 73523 (TC) 73523 (26) 73551 (RT) 73551 (LT)
73551 (50) 73551 (TC) (RT) 73551 (TC) (LT) 73551 (TC) (50) 73551 (26) (RT)
73551 (26) (LT) 73551 (26) (50) 73552 (RT) 73552 (LT) 73552 (50)
73552 (TC) (RT) 73552 (TC) (LT) 73552 (TC) (50) 73552 (26) (RT) 73552 (26) (LT)
73552 (26) (50) 77770 77770 (TC) 77770 (26) 77771
77771 (TC) 77771 (26) 77772 77772 (TC) 77772 (26)
78265 78265 (TC) 78265 (26) 78266 78266 (TC)
78266 (26) 80081 81170 81218 81272
81273 81276 81311 81314 88350
88350 (TC) 88350 (26) 92537 92537 (TC) 92537 (26)
92538 92538 (TC) 92538 (26) 99177 D0251
D9223 D9243 E0465 (RR) E0466 (RR) G0297
G0297 (TC) G0297 (26) G0476 G0476 (FP) G0477
G0477 (QW) G0478 G0479 G0480 G0481
G0482 G0483

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

Procedure Codes and Modifiers
33979 33979 (80) 33980 33980 (80) 44204 44204 (80)
49423 49423 (SG) 49424 49424 (SG) 81210 81332
99174 G0433 G0433 (QW) G0433 (FP) G0433 (QW) (FP)

 The following procedure codes are being end-dated from the MA Program Fee Schedule as a result of the 2016 HCPCS updates:

Procedure Codes
21805 31620 37202 39400 47136 47500
47505 47510 47511 47525 47530 47560
47561 47630 50392 50393 50394 50398
64412 67112 70373 72010 72069 72090
73500 73510 73520 73530 73540 73550
74305 74320 74327 74475 74480 75896
75980 75982 77776 77777 77785 77786
77787 88347 90645 90646 90669 90692
90693 90703 90704 90705 90706 90708
90719 90721 90725 90727 90735 92543
95973 A7011 D0260 D9220 D9221 D9241
E0450 E0460 E0461 E0463 G0431 G6018
G6019 G6020 G6022 G6023 G6024 G6025
G6030 G6031 G6032 G6034 G6035 G6036
G6037 G6038 G6039 G6040 G6042 G6043
G6044 G6045 G6046 G6047 G6049 G6050
G6051 G6052 G6053 G6054 G6056 G6057
G6058 J0886 J7302

 Procedure code J0890 is being end-dated from the MA Program Fee Schedule, because the manufacturer discontinued the drug.

 No new authorizations will be issued for the procedure codes being end-dated on and after July 1, 2016. For any of the previously listed procedure codes that had a prior authorization issued before July 1, 2016, 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 July 1, 2017, for those services that were previously prior authorized.

Prior Authorization Requirements

 The following laboratory 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 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
81170 81210 81218 81272 81273
81276 81311 81314 81332

 The following durable medical equipment procedure code and modifier combinations are being added to the MA Program Fee Schedule and require prior authorization with the first month of rental as authorized under section 443.6(b)(3) of the code:

Procedure Codes and Modifiers
E0465 (RR) E0466 (RR)

 The following procedure codes and modifiers being added to the MA Program Fee Schedule are considered advanced radiology services 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.pa.gov/publications/bulletinsearch/bulletinselected/index.htm?bn=01-14-42#.VxaDuE32ZtQ.

Procedure Codes and Modifiers
G0297 G0297 (TC) G0297 (26)

Updates to Procedure Codes Currently on the MA Program Fee Schedule

Dental Services

 The Department is increasing the maximum number of billable units for procedure code D5660 from 1 to 2 units per day based on clinical review.

End Stage Renal Dialysis Services

 With the closure of procedure code J0886 by CMS, the Department is increasing the maximum number of billable units for procedure code Q4081 from 9 to 400 units per day so providers may continue to bill for the full dosage of the drug currently allowed.

Optometrist Services

 Provider Type (PT)/Specialty (Spec) 18/180 (Optometrist) has been added to the following surgical, radiology and medical procedure code/modifier combinations in places of service (POS) 21 (inpatient hospital), 24 (ambulatory surgical center) and 11 (office), as indicated, based upon provider requests and clinical review:

Procedure Codes Modifiers POS
65778 RT/LT/50 21, 24
68761 E1, E2, E3, E4 11
76510 RT/LT/50 and RT/LT/50 TC 11
76511 RT/LT/50 and RT/LT/50 TC 11
76512 RT/LT/50 and RT/LT/50 TC 11
76516 No modifier and TC 11
76519 No modifier and TC 11
92025 No modifier and TC 11

 The post-operative period for surgical procedure code 65778 is being decreased from 90 to 0 days, to align with CMS's guidance.

 Radiology procedure code 76512 will have the right (RT), left (LT) and bilateral (50) modifiers added as the procedure may be performed laterally or bilaterally. As a result, the Department is also increasing the billable units from one to two per day.

Physician Services

 Surgical procedure code 43273 will expand to include all physician specialties by opening PT/Spec 31/All and end-dating PT 31 (physician) specialties 318 (general practice), 319 (surgery), 322 (internal medicine), 341 (radiology) and 345 (pediatrics) as the Department has determined that it is appropriate for all physician specialties to perform this service.

 Additionally, POS 11 is being end-dated for procedure code 43273 as the Department has determined that the office setting is not appropriate for the performance of this service.

Clinic Services

 Clinic procedure code 68761 will be end-dated for PT/Spec 08 (clinic)/All and will be opened for PT/Spec 08/082 (independent medical/surgical clinic) as the Department has determined that it is only appropriate for this provider to perform this service in this setting.

Therapist Services

 Medical procedure code 97110 will have PT/Spec combination 17/171 (occupational therapist) opened in POS 11, 12 (home), and 99 (community) based upon provider requests and clinical review.

Laboratory Services

 Laboratory procedure code 88346 will have the technical component (TC) modifier end-dated for PT/Spec/POS 28/280/81 (independent laboratory). Additionally, the Department is reducing the maximum number of billable units for procedure code 88346 from five to one per day as a result of CMS updating the code descriptions.

 The Department has determined that there will no longer be a prior authorization required for laboratory procedure codes S3854 and 81519.

Modifier Updates

QW Modifier

 The Department is adding the QW (CLIA waived test) informational modifier to laboratory procedure code 87631 that CMS identifies as a Clinical Laboratory Improvement Amendments (CLIA) waived test. This information is described in MA Bulletin 01-12-67, and others, Clinical Improvement Amendment Requirements, and 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 Modifier
87631 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 QW

 When submitting claims for CLIA waived tests, the QW modifier must be reflected with the applicable procedure code for the claims to process correctly.

 The Department is also adding the PT/Spec/POS and modifiers, as indicated, to laboratory procedure code 87631 as a result of the latest tests listed with CMS as CLIA waived tests:

Procedure Code PT/Spec/POS Modifiers
87631 08/082/49 (independent med/surg clinic) No modifier and QW
09/All/11 (CRNP) No modifier and QW
31/All/11 No modifier and QW
33/335/11 (certified nurse midwife) No modifier and QW

Open Places of Service

 The following procedure codes will have POS 23 and 99 (Special Treatment Room) opened for the 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
43274 31/All 99
43275 31/All 99
43276 31/All 99
43277 31/All 99
43278 31/All 99
74328 31/All 99
74329 31/All 99
74330 31/All 99
88346 27/All 23

End-Date Places of Service

 The following procedure codes will have POS 11, 22 (outpatient hospital), 23, 31 (skilled nursing facility), 32 (nursing facility), 49 (independent clinic) and/or 99 (Special Treatment Room) end-dated, for the PT/Spec combinations as indicated, because the Department has determined that these settings are not appropriate for the performance of these services:

Procedure Code PT/PS POS
43260 01/017
31/All
23
01/All (inpatient hospital)
23
4326201/183 22
08/All (clinic) 49
31/All 11 and 23
01/All 23
4326301/183 22
08/All 49
31/All 11 and 23
43264 01/All 23
31/All
43265 01/All 23
01/183 22
08/All 49
31/All 23
43273 01/183 22
31/318
31/319
31/32211
31/341
31/345
68761 01/All 23
31/All 23, 99
74328 31/All 22
74329 31/All 22
74330 31/All 22
76512 01/16
01/1723
31/All 23, 31, 32
76516 01/016 23
01/017
31/All
76519 01/016 23
01/017
31/All 23, 31, 32
88346 27/All (dentist)
31/All 11

Fee Adjustment

 The Department is adding the SG (facility service) pricing modifier to surgical procedure code 44950 in POS 24 for PT/Spec combinations 01/021 (short procedure unit) and 02/020 (ambulatory surgical center):

Procedure Code
and Modifier
Description Current Fee MA Fee
Effective
July 1, 2016
44950 (SG) Appendectomy NA $776.00

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. A 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 2016-2017 is $0.675 million ($0.325 million in State funds). The estimated cost for Fiscal Year 2017-2018 is $0.810 million ($0.390 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-1046. (1) General Fund; (2) Implementing Year 2015-16 is $0; (3) 1st Succeeding Year 2016-17 is $325,000; 2nd Succeeding Year 2017-18 through 5th Succeeding Year 2020-21 are $390,000; (4) 2014-15 Program—$564,112,000; 2013-14 Program—$428,041,000; 2012-13 Program—$718,947,000; (7) MA—FFS; (8) recommends adoption. Funds have been included in the budget to cover this increase.

[Pa.B. Doc. No. 16-1089. Filed for public inspection June 24, 2016, 9:00 a.m.]



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