Summary
Effective for dates of service on and after August 29, 2022, Pennsylvania's MA Program Fee Schedule adds procedure codes from the 2022 HCPCS updates and other codes based on provider requests or clinical review, and end-dates a list of procedure codes for which no new authorizations will be issued. Prior authorization is required for 81415, 81417, B4105, Q4186, D3921, D9947, L8619 (NU), L8692 (NU) and L8694. Many listed surgical codes now allow RT, LT or 50 modifiers and carry new unit or lifetime limits, and several place of service combinations were end-dated for listed surgical codes.
Get alerts when payers change rules like this one
We check Pennsylvania Medicaid (DHS) and other payers every day and email you when a change matches your specialty and state.
Get Pennsylvania Medicaid (DHS) alertsPolicy Monitoring is free. No card required.
What to do
Action · 13 steps
01Already effective August 29, 2022: No new authorizations will be issued for the end-dated procedure codes on or after August 29, 2022.
02For end-dated codes that had a prior authorization issued Previously due August 29, 2022 (date passed; verify current applicability), submit claims with the end-dated code as set forth in that authorization; the Department accepts those claims until August 29, 2023 for services previously prior authorized.
03Prior authorization is required for 81415, 81417, B4105, Q4186, D3921, D9947, L8619 (NU), L8692 (NU) and L8694.
04For the listed surgical codes that may be performed unilaterally or bilaterally, add the RT, LT and/or 50 modifiers, with or without the 80 modifier, for PT/Spec/POS 31/All/21 and 31/All/24.
05Remove the 50 modifier from 32442 and the 80 modifier from 69535.
06Observe the updated limits: 29826 is limited to once per day; 49491 and 49492 are limited to once per right side and once per left side per day; 30160, 32442, 44157, 44158, 45121, 49250, 51925, 52649, 55801 and 55821 are limited to once per lifetime; and 69535 is limited to once per right side and once per left side per lifetime.
07For take-home supplies of naloxone, use G1028 with one of the listed primary procedure codes, limited to one per 30 days.
08Add the QW modifier to 87801 for the listed CLIA waived test settings.
09For 99188, POS 12 is added for PT/Spec 09 and 31, and the maximum age changes from 4 to 20.
10Codes with the SG modifier in the short procedure unit are paid the facility support component fee of $776.00.
11Managed care organizations may impose service limits but may not impose limits more restrictive than the fee-for-service limits, and must notify network providers and members before implementing them.
12Service limit waivers are requested through the 1150 Administrative Waiver (Program Exception) process.
13Check current applicability before acting on any date in this bulletin.
Codes mentioned
01935019362131033470337224385043855591356319463195631966319863199697156971876101761029256192564935309353193532935339356193562G2064G20650193701938019390194001941019426305263053669896699168841697166971969726697278265383521860158603686037860518605286053862318636286363865969062690627906719067790759933199359393594935959359693597935989942499426D3921D9947D9948D9949G1028G221552441524428141581417905879332595800B4105D4346L8619L8692L8694Q418627078271402714727151272262722727228272452740527407275072751429826301603244244157441584512149250494914949251925526495580155821695359918887801T1015
Original notice
MAB2022082602
pa.gov · Always check the source before changing claims.
Related changes
See all Pennsylvania Medicaid (DHS) changes →MAB2024021301HighEffective Mar 1, 2024 · Provider BulletinMAB2022082603MediumEffective Aug 29, 2022 · Provider BulletinMAB2022091401MediumEffective Aug 29, 2022 · Provider BulletinMAB2024012401MediumNo effective date · Provider BulletinBrowse every Pennsylvania Medicaid (DHS) change in the policy list
Related policy hubs
Pennsylvania Medicaid (DHS) policiesPA policy changesOrthopedicsCardiologyOphthalmologyUrologyGeneral SurgeryENT (Ear, Nose & Throat)DentistryOral & Maxillofacial SurgeryAudiologySleep MedicineOB-GYNPediatricsPathologyWound CareOncologyGeneticsAnesthesiologyPsychiatryCode 01935Code 01936Code 21310Code 33470Code 33722Code 43850Code 43855Code 59135Code 63194Code 63195Code 63196Code 63198Code 63199Code 69715Code 69718Code 76101Code 76102Code 92561Code 92564Code 93530Code 93531Code 93532Code 93533Code 93561Code 93562Code G2064Code G2065Code 01937Code 01938Code 01939Code 01940Code 01941Code 01942Code 63052Code 63053Code 66989Code 66991Code 68841Code 69716Code 69719Code 69726Code 69727Code 82653Code 83521Code 86015Code 86036Code 86037Code 86051Code 86052Code 86053Code 86231Code 86362Code 86363Code 86596Code 90626Code 90627Code 90671Code 90677Code 90759Code 93319Code 93593Code 93594Code 93595Code 93596Code 93597Code 93598Code 99424Code 99426Code D3921Code D9947Code D9948Code D9949Code G1028Code G2215Code 52441Code 52442Code 81415Code 81417Code 90587Code 93325Code 95800Code B4105Code D4346Code L8619Code L8692Code L8694Code Q4186Code 27078Code 27140Code 27147Code 27151Code 27226Code 27227Code 27228Code 27245Code 27405Code 27407Code 27507Code 27514Code 29826Code 30160Code 32442Code 44157Code 44158Code 45121Code 49250Code 49491Code 49492Code 51925Code 52649Code 55801Code 55821Code 69535Code 99188Code 87801Code T1015