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PA Bulletin, Doc. No. 15-1937



Medical Assistance Program Fee Schedule Addition

[45 Pa.B. 6455]
[Saturday, October 31, 2015]

 In accordance with 55 Pa. Code § 1150.61(a) (relating to guidelines for fee schedule changes), the Department of Human Services (Department) announces the addition of procedure codes to the Medical Assistance (MA) Program Fee Schedule for three-dimensional (3D) mammography, also known as ''digital tomosynthesis,'' effective for dates of service on and after December 1, 2015.


 On October 5, 2015, Governor Tom Wolf announced that 3D mammograms, a service also known as tomosynthesis, are included under State law as a mammographic examination and must be covered by insurers in the same manner as traditional two-dimensional (2D) mammograms. Tomosynthesis is becoming more common as many health care facilities in this Commonwealth are replacing 2D mammography technology with 3D mammography technology, offering new opportunities to diagnose breast cancer and providing life-saving treatment earlier than ever.


 The Department is adding procedure codes 77061, 77062, 77063 and G0279 to the MA Program Fee Schedule to ensure that quality diagnostic testing and preventive breast cancer services are available to individuals enrolled in the MA Program.

 The professional component fee (billed with modifier 26), the technical component fee (billed with modifier TC) and the total fee (billed with no modifier), as applicable, are set forth as follows:

Procedure Code Description Pricing
Modifier 26
Modifier TC
No Modifier
77061 Digital breast tomosynthesis; unilateral $25.68 $22.51 $48.19
77062 Digital breast tomosynthesis; bilateral $25.68 $22.51 $48.19
77063 Screening digital breast tomosynthesis, bilateral $23.98 $20.05 $44.03
G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral $24.26 $19.25 $43.51

 The Department will issue an MA Bulletin to providers regarding tomosynthesis.

Fiscal Impact

 The estimated cost for Fiscal Year 2015-2016 is $0.054 million ($0.026 million in State funds) in the MA Outpatient Program and for Fiscal Year 2016-2017 is $0.128 million ($0.062 million in State funds) in the MA Outpatient Program as a result of adding procedure codes to the MA Program Fee Schedule.

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 Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered for any subsequent revision 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 at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).


Fiscal Note: 14-NOT-980. (1) General Fund;

 (7) MA—Outpatient; (2) Implementing Year 2015-16 is $260,000; (3) 1st Succeeding Year 2016-17 through 5th Succeeding Year 2020-21 are $620,000; (4) 2014-15 Program—$348,741,000; 2013-14 Program—$264,179,000; 2012-13 Program—$450,835,000;

 (7) MA—Capitation; (2) Implementing Year 2015-16 is $0; (3) 1st Succeeding Year 2016-17 through 5th Succeeding Year 2020-21 are $0; (4) 2014-15 Program—$4,000,000,000; 2013-14 Program—$3,900,000,000; 2012-13 Program—$3,600,000,000;

 (8) recommends adoption. Funds have been included in the budget to cover this increase.

[Pa.B. Doc. No. 15-1937. Filed for public inspection October 30, 2015, 9:00 a.m.]

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