Prior Authorization for Certain Hospital Outpatient Department (OPD) Services

Update 6/15/2020:

CMS is removing 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 updated list of codes that require prior authorization as a condition of payment can be found below.

Update 05/19/2020:

CMS will host a Special Open Door Forum call to discuss the Prior Authorization Process and Requirements for Certain Outpatient Hospital Department Services on Thursday, May 28, from 1:30p.m. to 3:00p.m. Eastern Time. Presentation materials will be posted in the Downloads section below in advance of the call. For more information, please visit the Special Open Door Forums webpage.

Background:

Through the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS-1717-FC), 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:

  1. Blepharoplasty
  2. Botulinum toxin injections
  3. Panniculectomy
  4. Rhinoplasty
  5. Vein ablation

The full list of HCPCS codes requiring prior authorization is available here (PDF).  CMS will post additional information about this program on this website. 

Page Last Modified:
06/15/2020 03:11 PM