Summary
Effective May 26, 2020, the Medical Assistance fee schedule adds procedure codes from the 2020 HCPCS updates for dates of service on and after that date and end-dates a list of older codes. Prior authorization is required for the added advanced radiology codes in the 78429 through 78835 range and for orthodontic codes D8703 and D8704, and no new authorizations are issued for end-dated codes on or after May 26, 2020.
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What to do
Action · 10 steps
01Already effective May 26, 2020: The billing team must use the added procedure codes for dates of service on and after May 26, 2020, with the modifiers, fees, units, limits and post-operative days shown in the attached 2020 HCPCS Updates chart and the MA Program Fee Schedule.
02The billing team must obtain prior authorization before billing the advanced radiology codes 78429 through 78835 listed with the modifiers TC and 26, following the process in MA Bulletin 01-14-42 titled Advanced Radiologic Imaging Services, and must obtain prior authorization for orthodontic codes D8703 and D8704.
03For end-dated codes, no new authorizations are issued on or after May 26, 2020.
04Where a prior authorization was issued Previously due May 26, 2020 (date passed; verify current applicability) for an end-dated code, submit claims using the end-dated code as set forth in that authorization, which the Department accepts through May 26, 2021 for previously authorized services.
05When a service or item is needed beyond the service limits, request a waiver through the 1150 Administrative Waiver (Program Exception) process.
06For members in the managed care delivery system, direct coding and billing questions to the appropriate managed care organization, since MCOs may not impose service limits more restrictive than the FFS limits.
07Surgical fees include postoperative visits by the performing practitioner for the number of post-operative days listed in the fee schedule.
08For dental codes, see MA Bulletin 27-20-01 titled Medical Assistance Program Dental Fee Schedule Update, effective May 26, 2020.
09Keep each service location's Medical Assistance enrollment current by revalidating every 5 years and submitting applications at least 60 days before the revalidation date.
10Check current applicability of these codes and requirements before relying on them, since this change took effect in 2020.
Codes mentioned
15769157711577215773157742070020701207022070320704207052160121602216033301633017330183301933858338593387134717347183570235703469484901349014623286232966987669887422174248784297843078431784327843378434784597849178492788307883178832788358018780285813078130892201922029398593986957009570595706957079570895709957109571195712957139571495715957169571795718957199572095721957229572395724957259572696156961589615996164961659616796168971299713099490D1551D1552D1553D1556D1557D1558D8703D8704G2064G2065G2066192601927119272193042092633010330113301533860338703572135741357614340164402644106441374241742457424774249742607693078205782067832078607786477871078805788067880793299958279583195832958339583495950959519595395956961509615196152961539615497127D1550D1555G0365
Original notice
MAB2020052601
pa.gov · Always check the source before changing claims.
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