NOTICES
DEPARTMENT OF HUMAN SERVICES
Medical Assistance Program Fee Schedule Revisions; 2019 Healthcare Common Procedure Coding System Updates and Fee Adjustments; Prior Authorization Requirements
[49 Pa.B. 4605]
[Saturday, August 17, 2019]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 19, 2019.
The Department is adding and end-dating procedure codes as a result of implementing the 2019 updates published by the Centers for Medicare & Medicaid Services (CMS) to the Healthcare Common Procedure Coding System (HCPCS). The Department is also adding other procedure codes and making changes to procedure codes currently on the MA Program Fee Schedule, including fee adjustments. As follows, some of the procedure codes being added to the MA Program Fee Schedule will require prior authorization. The Department will also issue an MA Bulletin to advise all enrolled providers of the changes in this notice, to include the fee adjustments.
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 2019 HCPCS updates:
Procedure Codes and Modifiers
10004 10005 10005 (SG) 10006 10007 10007 (SG) 10008 10009 10009 (SG) 10010 10011 10012 11102 11102 (SG) 11103 11104 11104 (SG) 11105 11106 11106 (SG) 11107 27369 (RT) 27369 (LT) 27369 (50) 33285 33285 (SG) 33286 33286 (SG) 36572 36572 (SG) 36573 36573 (SG) 38531 (SG) 38531 (RT) 38531 (LT) 38531 (50) 43762 43763 43763 (SG) 50436 (SG) 50436 (RT) 50436 (LT) 50436 (50) 50437 (SG) 50437 (RT) 50437 (LT) 50437 (50) 77046 77046 (TC) 77046 (26) 77047 77047 (TC) 77047 (26) 77048 77048 (TC) 77048 (26) 77049 77049 (TC) 77049 (26) 81163 81164 81165 81166 81167 81329 81336 81337 81596 83722 92273 92273 (TC) 92273 (26) 92274 92274 (TC) 92274 (26) 95976 95977 95983 95984 96112 96113 96121 96130 96131 96132 96133 99491 0509T 0509T (TC) 0509T (26) A5514 (RT) A5514 (LT) A5514 (50) D1516 D1516 (SG) D1517 D1517 (SG) V5171 V5172 V5181 V5211 V5212 V5213 V5214 V5215 V5221 The Department is adding the following procedure codes, and procedure code and modifier combinations to the MA Program Fee Schedule based upon provider requests or clinical review:
Procedure Codes and Modifiers
22853 22853 (80) 81015 81162 81528 82542 91200 91200 (TC) 91200 (26) 99484 99492 99493 99494 A4333 A4398 A4399 A4432 A4433 D0140 D1320 E0277 (NU) E0277 (RR) E0986 (NU) E0986 (RR) E1012 (NU) E1012 (RR) The Department is end-dating the following procedure codes from the MA Program Fee Schedule as a result of the 2019 HCPCS updates:
Procedure Codes
10022 11100 11101 20005 27370 31595 33282 33284 41500 46762 50395 61332 61480 61610 61612 64508 66220 76001 77058 77059 78270 78271 78272 81211 81213 81214 92275 95974 95975 95978 95979 96101 96111 96118 96119 D1515 K0903 V5170 V5180 V5210 V5220 Prior Authorization Requirements
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 Human Services Code (code) (62 P.S. § 443.6(b)(7)), and as described in MA Bulletin 01-14-42 titled Advanced Radiologic Imaging Services which may be viewed online at http://www.dhs.pa.gov/publications/bulletinsearch/bulletinselected/index.htm?bn=01-14-42.
Procedure Codes and Modifiers
77046 77046 (TC) 77046 (26) 77047 77047 (TC) 77047 (26) 77048 77048 (TC) 77048 (26) 77049 77049 (TC) 77049 (26) The following durable medical equipment (DME) procedure codes and modifier combinations being added to the MA Program Fee schedule will require prior authorization. Procedure codes with the NU modifier now require prior authorization for purchase, as authorized under section 443.6(b)(2) of the code, and procedure codes with RR modifier now require prior authorization after 3 months of rental under section 443.6(b)(3) of the code:
Procedure Codes and Modifiers
E0277 (NU) E0277 (RR) E0986 (NU) E0986 (RR) E1012 (NU) E1012 (RR) The following prosthetic procedure codes 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 and Modifiers
V5171 V5172 V5181 V5211 V5212 V5213 V5214 V5215 V5221 Updates to Procedure Codes Currently on the MA Program Fee Schedule
Physicians' Services
The Department is adding modifiers RT (right side), LT (left side) and 50 (bilateral) to the following procedure codes and modifier combinations for Provider Type (PT)/Specialty (Spec)/Place of Service (POS) combination 31 (Physician)/All/21 (Inpatient Hospital) as these services may be performed laterally or bilaterally by all physician specialties in this setting:
Procedure Codes
23470 23470 (80) 23472 23472 (80) 27122 27122 (80) 27130 27130 (80) 27132 27132 (80) 27138 27138 (80) 27445 27445 (80) 27446 27446 (80) 27447 27447 (80) 27486 27486 (80) 27487 27487 (80) The Department is end-dating PT/Spec/POS combinations 01 (Inpatient Facility)/All/23 (Emergency Room), 01/183 (Hospital Based Medical Clinic)/22 (Outpatient Hospital), and 08 (Clinic)/All/49 (Independent Clinic) for the following procedure codes as the settings were determined to be clinically inappropriate:
Procedure Codes
23470 27445 27446 27447 27486 27487 The Department is end-dating POS 23 and 99 (Special Treatment Room) for the following surgical procedure codes and modifiers for PT/Spec combination 31/All as the settings were determined to be clinically inappropriate:
Procedure Codes
23470 23470 (80) 27445 27445 (80) 27446 27446 (80) 27486 27486 (80) 27487 27487 (80) The Department is updating unit or service limits, or both, for the following surgical procedure codes to allow for bilateral services and to limit to once per lifetime, as a result of clinical review:
Procedure Code Old Unit Limit New Unit Limit Present Limit New Limit 23470 1:1 1:2 Once per day Once per right side per lifetime and once per left side per lifetime 23472 1:1 1:2 Once per day Once per right side per lifetime and once per left side per lifetime 27122 1:2 1:2 Twice per day Once per right side per lifetime and once per left side per lifetime 27130 1:1 1:2 Once per day Once per right side per lifetime and once per left side per lifetime 27132 1:1 1:2 Once per day Once per right side per lifetime and once per left side per lifetime 27138 1:1 1:2 Once per day Once per right side and/or once per left side per day 27446 1:1 1:2 Once per day Once per right side and/or once per left side per day 27447 1:1 1:2 Once per day Once per right side per lifetime and once per left side per lifetime 27487 1:1 1:2 Once per day Once per right side and/or once per left side per day The Department is opening the following PT/Spec combinations for surgical procedure code 49465, as determined by clinical review, in POS 11 (Office) 21, 22, 23 and/or 99:
Procedure Code New PT/Spec POS 49465 01/017 (Emergency Room Arrangement 2) 23 01/183 22 31/All 11, 21, 23, 99 The Department is end-dating PT 31/Specialties 319 (Surgery), 322 (Internal Medicine) and 341 (Radiology) for surgical procedure code 49465, as clinical review determined it is appropriate for all physician specialties to perform this service.
The Department is opening PT/Spec 31/All in POS 21 and end-dating PT 31 specialties 318 (General Practitioner), 319, 322 and 328 (Obstetrics and Gynecology) for surgical procedure code 58294 with and without the pricing modifier 80 (Assistant Surgeon), as the Department determined it is appropriate for all physician specialties to perform this service.
The Department is opening PT/Spec combinations for procedure code 95971, as determined by clinical review, in POS 22 and 49:
Procedure Code New PT/Spec POS 95971 01/183 22 08/082 (Independent Medical/Surgical Clinic) 49 Procedure codes 95970 and 95971 will have POS 99 added for the PT/Spec 31/All as the Department determined this setting is appropriate for the performance of these services.
The Department is end-dating the informational modifier 78 (unplanned return to the operating room) for medical procedure codes 95971 and 95972 as clinical review determined that modifier 78 does not apply to these procedure codes.
Ambulatory Surgical Center/Short Procedure Unit Services
The Department is opening PT/Spec combinations 01/021 (SPU), 02 (ASC)/020 (ASC), or both for the procedure codes identified below in POS 24 (ASC) with the SG (ASC/SPU facility support component) modifier. The Department determined these procedure codes are appropriate for additional specialties, can be performed safely in a SPU, ASC, or both, and will be paid the facility support component fee of $776:
Procedure Code New PT/Spec POS 10021 (SG) 01/021 24 02/020 22551 (SG) 01/021 24 02/020 23473 (SG) 01/021 24 58294 (SG) 01/021 24 58553 (SG) 02/020 24 The Department is adding POS 24 for PT/Spec 31/All for the following procedure codes and modifier combinations as the result of clinical review and the Department's determination that this setting is appropriate for the performance of these services:
Procedure Codes
10021 22551 22551 (80) 22552 22552 (80) 23473 (RT) 23473 (LT) 23473 (50) 23473 (80) (RT) 23473 (80) (LT) 23473 (80) (50) 49465 58294 58294 (80) 95970 95971 95972 The Department is adding modifiers RT, LT and 50 to the following procedure codes and modifier combinations for PT/Spec/POS combination 31/All/24 as these services may be performed laterally or bilaterally by these providers in this setting:
Procedure Codes
23470 23470 (80) 27446 27446 (80) 27447 27447 (80) The Department is end-dating PT/Spec/POS combinations 01/021/24 or 02/020/24, or both for the following procedure codes with the SG modifier as the setting was determined to be clinically inappropriate for the PT/Spec combinations:
Procedure Code End-dated PT/Spec/POS combinations 23470 (SG) 02/020/24 23472 (SG) 01/021/24; 02/020/24 27446 (SG) 02/020/24 27447 (SG) 02/020/24 27486 (SG) 01/021/24; 02/020/24 27487 (SG) 01/021/24; 02/020/24 The Department is end-dating POS 24 for the following surgical procedure codes and modifiers for PT/Spec combination 31/All as the setting was determined to be clinically inappropriate:
Procedure Codes
23472 23472 (80) 27130 27130 (80) 27486 27486 (80) 27487 27487 (80) Podiatrist Services
The Department is adding PT/Spec 14 (Podiatrist)/140 (Podiatrist) to procedure code 10021 in POS 11, 21, 23 and 24 as a result of clinical review because the Department determined it is appropriate for this provider to perform this service in these settings.
Laboratory Services
The Department is removing prior authorization requirements for the following laboratory procedure codes based on clinical review:
Procedure Codes
81212 81215 81216 81217 81220 81240 81241 81370 81371 81372 81373 81374 81375 81376 81377 81378 81379 81380 81381 81382 81383 81420 81435 81436 81507 The Department is adding a limitation of ''once per lifetime'' to the following laboratory procedure codes based on clinical review:
Procedure Codes
81370 81371 81372 81373 81374 81375 81376 81377 81378 81379 81380 81381 81382 81383 The Department is changing the limitations for procedure codes 81420 and 81507 from ''once per day'' to ''once per pregnancy'' based on clinical review.
The Department is adjusting the MA Program fee for the laboratory procedure codes identified as follows as they are used more widely, and industry rates have been reduced for these services:
Procedure Code Description Current Fee MA Fee Effective August 19, 2019 81216 BRCA2 (BRCA2, DNA repair associated) (for example, hereditary breast and ovarian cancer) gene analysis; full sequence analysis $1,482.35 $148.10 81220 CFTR (cystic fibrosis transmembrane conductance regulator) (for example, cystic fibrosis) gene analysis; common variants (for example, ACMG/ACOG guidelines) $1,092.53 $445.28 Neurobehavioral Status Exam
The Department is updating the procedure description (in bold as follows) and service limitation for procedure code 96116 due to the addition of new procedure 96121 for additional hours. The Department is adjusting the fee for procedure code 96116 to reflect the fee for the ''first hour'' of service.
Procedure Code New Procedure Description Present Limit New Limit Current Fee MA Fee Effective August 19, 2019 96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [for example, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour Up to 12 per day Once per day $52.50 $68.72 The Department is opening the following PT/Spec combinations in POS 11, 12 (Patient's Home), 15 (Mobile Unit), 21 or 57 (Non-Residential Substance Abuse Treatment Facility) for procedure code 96116 based on clinical review:
Procedure Code New PT/Spec POS 96116 08/074 (Mobile Mental Health Unit) 15 08/184 (Outpatient Drug and Alcohol) 12, 57 31/339 (Psychiatrist) 11, 21 The Department is end-dating the following PT/Spec combinations for procedure code 96116. Based on clinical review, the Department has determined it is not appropriate for these specialties to bill for this service.
Procedure Code End-dated PT/Spec 96116 11 (Mental Health/Substance Abuse)/548 (Therapeutic Staff Support) 11/549 (Mobile Therapy) 11/559 (Behavioral Specialist Consultant) The Department is adding POS 49 or 52 (Psychiatric Facility/Partial Hospitalization) to, and end-dating POS 11 and 99 from, procedure code 96116. The Department determined the new POS are appropriate and the end-dated POS are not appropriate for the provision of this service.
Procedure Code PT/Spec New POS End-dated POS 96116 08/110 (Psychiatric Outpatient Clinic) 49 11, 99 11/113 (Child Partial Psychiatric Hospital) 52 11, 99 11/114 (Adult Partial Psychiatric Hospital) 52 11, 99 DME and Medical Supplies
The Department is adding modifiers RT, LT and 50 to the following DME procedure codes, as these items may be provided laterally or bilaterally. Procedure codes with the NU modifier now require prior authorization for purchase, as authorized under section 443.6(b)(2) of the code. Prior authorization for procedure codes with the RR modifier is changing from ''with first month's rental'' to ''after three months of rental'' under section 443.6(b)(3) of the code:
Procedure Codes
E0667 (NU) E0667 (RR) E0668 (NU) E0668 (RR) The Department is adding or changing limits to the following DME procedure codes:
Procedure Code Present Limit New Limit Reason E0651 (NU) No limit 1 per 3 calendar years This limit is based on clinical review. E0667 (NU) No limit 2 per 365 days This limit is added to permit bilateral items every 365 days. E0667 (RR) 1 per calendar month 2 per calendar month This item may be provided for each leg, so the maximum limit has been increased to allow for bilateral items. E0668 (NU) No limit 2 per 365 days This limit is added to permit bilateral items every 365 days. E0668 (RR) 1 per calendar month 2 per calendar month This item may be provided for each arm, so the maximum limit has been increased to allow for bilateral items. The Department is updating unit limits for the following procedure codes:
Procedure Code Old Unit Limit New Unit Limit Reason E0667 (NU)
E0667 (RR)1:1 1:2 This item may be provided for each leg, so the maximum limit has been increased to allow for bilateral items. E0668 (NU)
E0668 (RR)1:1 1:2 This item may be provided for each arm, so the maximum limit has been increased to allow for bilateral items. The Department is end-dating the NU pricing modifier for DME procedure code K0108 pertaining to the hardware for head support system as this is included as part of companion code E0955 (wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each).
The Department is adjusting the fee for medical supply procedure code A4455 to reflect the rate per ounce, as indicated in the procedure code description, and not by cubic centimeter:
Procedure Code Description Current Fee MA Fee Effective August 19, 2019 A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per oz. $0.04 $1.26 Fiscal Impact
The estimated cost for Fiscal Year 2019-2020 is $0.466 million ($0.222 million in State funds). The estimated cost for Fiscal Year 2020-2021 is $0.699 million ($0.334 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).
TERESA D. MILLER,
SecretaryFiscal Note: 14-NOT-1353. (1) General Fund; (2) Implementing Year 2019-20 is $222,000; (3) 1st Succeeding Year 2020-21 through 5th Succeeding Year 2024-25 are $334,000; (4) 2018-19 Program—$342,544,000; 2017-18 Program—$477,690,000; 2016-17 Program—$450,970,000; (7) MA—Fee-for-Service; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 19-1243. Filed for public inspection August 16, 2019, 9:00 a.m.]
No part of the information on this site may be reproduced for profit or sold for profit.This material has been drawn directly from the official Pennsylvania Bulletin full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
