MEDICAL ASSISTANCE BULLETIN
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1 ISSUE DATE March 17, 2015 SUBJECT EFFECTIVE DATE March 2, 2015 MEDICAL ASSISTANCE BULLETIN NUMBER BY Medical Assistance Program Fee Schedule Revisions Vincent D. Gordon, Deputy Secretary Office of Medical Assistance Programs PURE: The purpose of this bulletin is to announce changes to the Medical Assistance (MA) Program fee schedule. These changes are effective for dates of service on and after March 2, SCOPE: This bulletin obsoletes bulletin due to a typographical error. This bulletin applies to all MA enrolled providers who render services to beneficiaries in the MA fee-for-service delivery system. Providers rendering services to beneficiaries in the MA managed care delivery system should address any coding or billing questions to the appropriate managed care organization. BACKGROUND: The Department of Human Services (Department) is making updates to the MA Program fee schedule based upon payment indicators specified by the Centers for Medicare and Medicaid Services (CMS), in response to requests received from providers, and clinical reviews conducted by Department staff related to standards of practice, provider type/ specialty combinations (PT/Spec), places of service () and procedure code/modifier combinations. DISCUSSION: Physician Services Radiology procedure code is being added for PT/Spec 31 (Physician)/ All with modifier 26 (professional component) in 24 (Ambulatory Surgical Center (ASC))/Short Unit (SPU)) and 99 (Special Treatment Room). COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE DIRECTED TO: The appropriate toll free number for your provider type Visit the Office of Medical Assistance Programs Web site at
2 2 The following radiology procedure codes will have 21 (Inpatient Hospital), 24 and/or 99 added for PT/Spec 31/341 (Radiologist) with modifier 26 as indicated: Modifier Modifier , , , , , The following radiology procedure codes will be end-dated for PT/Spec 31/All and reopened for PT/Spec 31/341 in 21, 22 (Outpatient Hospital), 23 (Emergency Room) and/or 49 (Independent Clinic) with modifier 26 as indicated: Modifier Modifier , 22, , 22, , , , , , , , , , , , 22, , 22, , , Laboratory procedure codes and will be end-dated for PT/Spec 31/All and re-opened for PT/Spec 31/333 (Pathologist). Dental Services
3 code will have PT 27 (Dentist) end-dated because the procedure is outside the provider s scope of practice, beyond their scope of education or training, or both. Emergency Room Services Radiology procedures codes and will be end-dated for PT/Spec 01 (Inpatient Facility)/016 (ER Arrangement 1) in 23 because under this arrangement, payment would be made to the physician. Laboratory Services The following laboratory procedure codes will be end-dated for PT/Specs, indicated as follows, in 22, because the payment for these procedure codes is included in the hospital s per diem payment. PT/Spec /012 (Med Rehab Hospital) 01/014 (Med Rehab Unit) /019 (D&A Hospital) /441 (D&A Rehab Hospital) / Laboratory procedure codes 81000, and will be end-dated for PT/Spec 01/015 (Children s Specialty Hospital) because the Department does not enroll providers under this specialty. Modifier Updates Right/Left/50 Modifiers code will have the modifiers right (Rt), left (Lt) and bilateral (50) added because the procedure may be performed bilaterally. codes and will have modifiers Rt, Lt, and 50 end-dated because the procedure code description specifies a single side or bilateral service. TC/26/Total Modifiers The following radiology procedure codes will only be payable when submitted with modifier 26: 26 Modifier Pricing 26 Modifier Pricing $ $ $ $154.98
4 4 Laboratory procedure codes and will have the TC (technical component) modifier end-dated for PT/Spec 28 (Laboratory)/280 in 81 (Independent Laboratory) as only the total component may be billed. The following laboratory procedure codes will have PT/Spec 31/333 (Pathologist) added with the modifiers 26 and FP (family planning) in, as indicated, with applicable pricing: Modifier 26 Modifier Pricing $ , 22, $ , 22, $ , 22, $ , 22, $ , 22, $ , 22, $ , $ , 22, , FP $ , $ , 22, $ , 22, $ , 22, $ , 22, $ , 22, $ , 22, $ , 22, $ , 22, , FP $ , $ , 22, , FP $ , $ , 22, $ , 22, $ , 22, $ , 22, 23
5 5 The following laboratory procedure codes will have modifiers TC and FP added to PT/Spec, as indicated, with applicable pricing: PT/Spec Modifiers TC Modifier Pricing /183 TC 01/016; 01/017 TC 01/183 TC, FP 08/083 TC, FP 01/016; 01/017 TC 01/183 TC $8.80 $8.80 $6.19 The following radiology procedure code/modifier combinations will be end-dated for the PT/Spec in the indicated: PT/Spec Modifier(s) Comments 01/183 TC 22 The TC and 26 pricing modifiers are /All TC 11 not consistent with the CMS payment 31/All 26 11, 21, 22 methodology /All 26 11, 21, /All TC, Not separately billable in an office /All TC, setting /All TC, The following laboratory procedure code/modifier combinations will be end-dated for PT/Spec in the indicated because these are not consistent with CMS payment methodology: s Modifiers PT/Spec /All 11, 21, 22, 23 TC 01/016/ TC 01/ TC 28/ /All 11, 21, 22, 23 TC 01/016/ TC 01/ TC 28/ The following radiology procedure codes will have the total component (Total) and TC modifiers end-dated:
6 6 Comment This code is only open for 21 and 24 and covered by the inpatient DRG payment or the facility support payment This code is only open for 21 and covered in the inpatient DRG payment CMS payment methodology only allows payment for the modifier. The following radiology and laboratory procedure codes will have modifiers end-dated as indicated: s s Enddated Modifier Comments No Modifier Pricing TC Modifiers are not consistent with CMS $ TC payment methodology $ U7 Department error $ The following radiology and laboratory procedure codes will have PT/Spec/modifier combinations added in as indicated: PT/Spec Modifier /All /183 No modifier TC /183 No modifier End-Date Places of Service 01/183 01/016/017 28/280 01/183 01/016/017 28/280 No modifier No modifier The following radiology and laboratory procedure codes will have 11 (office), 22, 23, 24, 31 (skilled nursing facility), 32 (nursing facility), 49 and/or 99 end-dated, as indicated, because the Department has determined that these settings are not appropriate for the performance of these services:
7 7 s s , 31, , , 22, 23, 31, 32, , 22, 23, 31, 32, , 22, 23, 31, 32, , 22, 23, 31, 32, , 23, 31, , 23, 31, 32, , , 31, 32, , 32, , 23, 31, 32, , 31, 32, , 23, , 23, , 23, , 23, , 23, 31, 32, , 23, 31, 32, , 23, 31, 32, , 22, 23, , 22, 23, , 23, 31, 32, , 23, 31, 32, , 23, 31, 32, , 31, 32, , 31, 32, , 23, 31, 32, , 23, , , 23, Pricing Revisions MA regulations at 55 Pa. Section (a) relating to payment levels and notice of rate setting changes sets forth that the Department will establish maximum payment rates for MA covered services. The established maximum payment rates will not exceed the Medicare Upper Limit. The fees for the following radiology and laboratory procedure codes will be adjusted as follows: Total TC Modifier 26 Modifier $ $93.73 No Change $ $94.04 No Change $25.53 No Change No Change $83.30 No Change No Change $9.71 $6.65 No Change $9.71 $6.65 No Change $56.47 $38.98 No Change $76.07 $53.50 No Change
8 Limit Updates $12.92 No Fee No Fee $ $ No Change $ $ No Change $ $ No Change $ $ No Change $ $ No Change $ $ No Change $4.32 No Fee No Fee $14.65 No Fee $ $23.24 No Fee $ $24.55 No Fee $ $10.26 No Fee No Fee $3.23 No Fee No Fee $3.23 No Fee No Fee $29.31 No Fee $ $16.44 No Fee $ $30.95 No Fee $ $12.12 No Fee No Fee $18.70 No Fee No Fee $19.64 No Fee No Fee $8.75 No Fee No Fee $5.82 No Fee No Fee $47.87 No Fee No Fee $ No Change No Change The following radiology procedure codes will have changes to the fee schedule limits: Present Limit New Limit PROCEDURE: The MA Program Outpatient Fee Schedule will be updated to reflect these changes. Providers may access the on-line version of the fee schedule under the Office of Medical Assistance Programs website at:
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