Prior Authorization for Certain Hospital Outpatient Department (OPD) Services
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.
The full list of HCPCS codes requiring prior authorization is available here (PDF).
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.
More information on this process can be found in the Operational Guide and the Frequently Asked Questions below.
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.
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.
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:
- Botulinum toxin injections
- Vein ablation