Summary
Effective for dates of service on and after May 28, 2024, the Pennsylvania Medical Assistance fee-for-service program added codes including 58580, 61886, 61889, 61891, 61892, 76984, 76987, 76988, 76989, 81457, 81458, 81459, 81517, 86041, 86042, 86043, 92622, 92623, 93584 through 93588, 93241, 93245 through 93248, 90867 through 90869, 87428, 90694, A4287, D2991, G0136, and the lymphedema compression codes listed from A6520 to A6608. Codes A2019 and Q4158 require prior authorization, and codes 0014M, 74710, G2066 and K1005 were end-dated. Fees, limits and modifier rules also changed for codes 93297 and 93298, A4660, the compression garment codes A6530 through A6541 and A6545, S8424 and S8428.
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What to do
Action · 15 steps
01Already effective May 28, 2024: Billing team: the Department will not approve prior authorization requests for codes 0014M, 74710, G2066 and K1005 after May 27, 2024.
02For services previously prior authorized Previously due May 28, 2024 (date passed; verify current applicability), submit claims with the end-dated code named in that prior authorization notice, and the Department will accept those claims until May 28, 2025.
03Billing team: get prior authorization for A2019 and Q4158, which require it.
04Billing team: for 93297 and 93298 billed without a modifier at PT/Spec/POS 31/All/11, the MA fees are $44.94 and $75.06, and POS 27 is end-dated for PT/Spec 31/All on both codes.
05Billing team: add modifier 26 to 93297 and 93298 for the listed 31/All combinations, and use modifier TC for the listed 01/183/22 and 08/082/49 combinations as shown.
06Billing team: the modifier 50 is removed from the listed PT/Spec/POS combinations for A6530, A6531, A6532, A6533, A6534, A6535, A6536, A6537, A6538, A6545, S8424 and S8428.
07Billing team: the limit for A4660 changed from 1 per 5 calendar years to 1 per 3 calendar years.
08Billing team: the lymphedema compression codes are only to be used when an ICD-10 diagnosis of lymphedema is on the claim.
09Billing team: observe the updated unit and combined limits in the source's limit tables, including the combined limit of 3 per right side and 3 per left side per 180 days for the lower extremity compression garments listed.
10Billing team: 90867 is limited to once per initial treatment, and 90868 and 90869 are limited to once per day.
11Billing team: 90694 is limited to once per 270 days per flu season.
12Billing team: G0136 with modifier FQ applies to audio-only communication technology at the listed places of service.
13Billing team: when a provider determines a beneficiary needs a service above an established limit, the provider may request a waiver through the 1150 Administrative Waiver Program Exception process.
14Billing team: for managed care beneficiaries, send coding and billing questions to the appropriate MCO.
15Billing team: check the online MA Program Fee Schedule for the updated fees.
Codes mentioned
5858061886618896189161892769847698776988769898145781458814598151786041860428604387428906949086790868908699262292623932419324593246932479324893297932989358493585935869358793588A2019A4287A4660A6520A6522A6524A6526A6528A6530A6531A6532A6533A6534A6535A6536A6537A6538A6539A6540A6541A6545A6552A6554A6566A6568A6570A6572A6575A6578A6581A6582A6583A6585A6586A6587A6588A6589A6594A6595A6596A6597A6598A6599A6600A6601A6602A6603A6604A6605A6606A6607A6608S8424S8428D0190D0191D2991G0136Q415874710G2066K1005
Original notice
MAB2024052801
pa.gov · Always check the source before changing claims.
Related changes
See all Pennsylvania Medicaid (DHS) changes →MAB2024090901HighEffective Sep 9, 2024 · Provider BulletinMAB2024060501MediumEffective May 28, 2024 · Provider BulletinMicrosoft Word - 2010 HCPCS Updates MAB _B Yakum_ 11-09-10MediumEffective Jan 3, 2011 · CodingMAB2020052601MediumEffective May 26, 2020 · Provider BulletinBrowse every Pennsylvania Medicaid (DHS) change in the policy list
Related policy hubs
Pennsylvania Medicaid (DHS) policiesPA policy changesCardiologyDentistryFamily MedicineNeurosurgeryPsychiatryPathologyRadiologyVascular SurgeryWound CareCode 58580Code 61886Code 61889Code 61891Code 61892Code 76984Code 76987Code 76988Code 76989Code 81457Code 81458Code 81459Code 81517Code 86041Code 86042Code 86043Code 87428Code 90694Code 90867Code 90868Code 90869Code 92622Code 92623Code 93241Code 93245Code 93246Code 93247Code 93248Code 93297Code 93298Code 93584Code 93585Code 93586Code 93587Code 93588Code A2019Code A4287Code A4660Code A6520Code A6522Code A6524Code A6526Code A6528Code A6530Code A6531Code A6532Code A6533Code A6534Code A6535Code A6536Code A6537Code A6538Code A6539Code A6540Code A6541Code A6545Code A6552Code A6554Code A6566Code A6568Code A6570Code A6572Code A6575Code A6578Code A6581Code A6582Code A6583Code A6585Code A6586Code A6587Code A6588Code A6589Code A6594Code A6595Code A6596Code A6597Code A6598Code A6599Code A6600Code A6601Code A6602Code A6603Code A6604Code A6605Code A6606Code A6607Code A6608Code S8424Code S8428Code D0190Code D0191Code D2991Code G0136Code Q4158Code 74710Code G2066Code K1005