Prior Authorization and Pre-Claim Review Initiatives
Prior Authorization for Certain Hospital Outpatient Department (OPD) Services
Through the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS-1717-FC (PDF)), CMS established a nationwide prior authorization process and requirements for certain hospital outpatient department (OPD) services. This process serves as a method for controlling unnecessary increases in the volume of these services.
CMS believes prior authorization for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care – while protecting the Medicare Trust Fund from improper payments and, at the same time, keeping the medical necessity documentation requirements unchanged for providers.
The following hospital OPD services will require prior authorization when provided on or after July 1, 2020:
- Botulinum toxin injections
- Vein ablation
The following hospital OPD services will require prior authorization when provided on or after July 1, 2021:
- Implanted Spinal Neurostimulators
- Cervical Fusion with Disc Removal
Download the full list of HCPCS codes requiring prior authorization (PDF).
Updates are provided in reverse chronological order; scroll down for earlier updates.
Removal of HCPCS code
Beginning for dates of service on or after January 7, 2022, CMS is removing CPT 67911 (correction of lid retraction) from the list of codes that require prior authorization as a condition of payment. This service is not likely to be cosmetic in nature and commonly occurs secondary to another condition. The full list of HCPCS codes (PDF) has been updated to reflect this change.
CMS revised the exemption process for the hospital OPD providers and extended the exemption cycle. OPD providers who are currently exempt should receive the notice of continued exemption by January 10, 2022. Exempt providers should not submit prior authorization requests. Providers who are not exempt should continue to submit prior authorization requests. More detailed information is provided in the Operational Guide and the Frequently Asked Questions in the Downloads section below.
CMS is temporarily removing CPT codes 63685 and 63688 from the list of OPD services that require prior authorization. The only service that will require prior authorization for implanted spinal neurostimulators is CPT code 63650. Providers who plan to perform both the trial and permanent implantation procedures using CPT code 63650 in the OPD will only require prior authorization for the trial procedure. When the trial is rendered in a setting other than the OPD, providers will need to request prior authorization for CPT code 63650 as part of the permanent implantation procedure in the hospital OPD.
As part of the Calendar Year 2021 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS-1736-FC), CMS is adding Implanted Spinal Neurostimulators and Cervical Fusion with Disc Removal to the nationwide prior authorization process for hospital outpatient department (OPD) services, effective July 1, 2021. These two services will be in addition to the existing list of services requiring prior authorization, which include blepharoplasty, botulinum toxin injection, rhinoplasty, panniculectomy, and vein ablation.
Additionally, MACs are in the process of identifying those hospital OPDs that will be exempt from the prior authorization process. Starting February 1, 2021 MACs began calculating the affirmation rate of initial prior authorization requests submitted. Hospital OPD providers who met the affirmation rate threshold of 90% or greater will receive a written Notice of Exemption no later than March 1, 2021. Those hospital OPDs will be exempt from submitting prior authorization requests for dates of service beginning May 1, 2021.
HCPCS Code Update 6/15/2020:
CMS removed HCPCS code 21235 (obtaining ear cartilage for grafting) from the list of codes that require prior authorization as a condition of payment, because it is more commonly associated with procedures unrelated to rhinoplasty that are not likely to be cosmetic in nature. The full list of HCPCS codes (PDF) has been updated to reflect this change.