Summary
Effective for dates of service on and after December 21, 2020, the Medical Assistance fee schedule adds, end-dates and updates procedure codes, modifiers, provider type and specialty combinations, places of service, prior authorization requirements, unit and service limits, and post-operative days for many services. The Department end-dated 15 vaccine procedure codes, including 90634 and 90748, and it changed the colorectal screening limit for code 81528 from one per 365 days to one per three years.
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What to do
Action · 12 steps
01Already effective December 21, 2020: Check the MA Program Fee Schedule for the procedure codes, modifiers, provider type and specialty, place of service, MA fee, prior authorization requirement and limit for each code before billing these services.
02Use the modifiers listed for each code in the attached fee schedule table, for example 29893 with the SG modifier for a short procedure unit in place of service 24, or 27130 with RT, LT or 50 modifiers for places of service 21 and 24 under 31/All.
03Surgical fees include the post-operative visits for the number of post-operative days listed in the fee schedule.
04Obtain prior authorization for CFTR gene analysis codes 81221, 81222 and 81223, which the fee schedule marks as requiring prior authorization.
05For durable medical equipment, procedure codes with the NU modifier require prior authorization for purchase, and procedure codes with the RR modifier require prior authorization after three months of rental, under 62 P.S.
06443.6(b)(2) and (b)(3).
07The Department removed prior authorization requirements for K0553, K0554 (NU) and K0554 (RR).
08For vaccine code 90662, bill with the place of service and provider type listed in the fee schedule.
09The Department accepts claims with the end-dated vaccine codes until December 21, 2021, so confirm the current code set in the fee schedule.
10Respect the service limits in the fee schedule, such as one visual field examination per calendar year for codes 92081, 92082 and 92083.
11Providers in managed care delivery should address questions to the managed care organization.
12Providers may request a 1150 Administrative Waiver for a service in excess of an established limit by following the provider handbook process.
Codes mentioned
298936065081221812228122390662961369613790634906499065090654906559065790658906609066190673906769068290690907339074836245362463624750389644206442100212002140022201150012140143201952019532713043281632678152892081920829208390791907929083290834908379084690847908759611696121961279613096131961329613396160H201095813A6206A6207A6208A6209A6210A6211A6212A6213A6214A6222A6223A6224A6266A4624A7030A7526B9002E0956E1028E1810K0553K0554U0001U0002
Original notice
MAB2021063001
pa.gov · Always check the source before changing claims.
Related changes
See all Pennsylvania Medicaid (DHS) changes →MAB2022082601MediumEffective Aug 26, 2022 · Provider BulletinMedical Assistance Program Vaccine Desk Reference UpdatesMediumEffective Nov 19, 2024 · Provider BulletinUpdates to the Medical Assistance Program Copayment Desk Reference MAB 99-17-06MediumEffective Jun 26, 2017 · Provider BulletinMAB2024090901HighEffective Sep 9, 2024 · Provider BulletinBrowse every Pennsylvania Medicaid (DHS) change in the policy list
Related policy hubs
Pennsylvania Medicaid (DHS) policiesPA policy changesAnesthesiologyGeneral SurgeryUrologyNeurosurgeryNeurologyOphthalmologyOptometryPsychiatryGastroenterologyGeneticsInfectious DiseasePathologyPain ManagementVascular SurgeryGeneral PracticePediatricsOrthopedicsPodiatryCode 29893Code 60650Code 81221Code 81222Code 81223Code 90662Code 96136Code 96137Code 90634Code 90649Code 90650Code 90654Code 90655Code 90657Code 90658Code 90660Code 90661Code 90673Code 90676Code 90682Code 90690Code 90733Code 90748Code 36245Code 36246Code 36247Code 50389Code 64420Code 64421Code 00212Code 00214Code 00222Code 01150Code 01214Code 01432Code 01952Code 01953Code 27130Code 43281Code 63267Code 81528Code 92081Code 92082Code 92083Code 90791Code 90792Code 90832Code 90834Code 90837Code 90846Code 90847Code 90875Code 96116Code 96121Code 96127Code 96130Code 96131Code 96132Code 96133Code 96160Code H2010Code 95813Code A6206Code A6207Code A6208Code A6209Code A6210Code A6211Code A6212Code A6213Code A6214Code A6222Code A6223Code A6224Code A6266Code A4624Code A7030Code A7526Code B9002Code E0956Code E1028Code E1810Code K0553Code K0554Code U0001Code U0002