The CMS is implementing a prior authorization program for certain hospital OPD services for DOS on or after 7/1/2020. 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 keeping the medical necessity documentation requirements unchanged for providers. As a condition of payment for DOS on or after 7/1/2020, a PAR is required for the following hospital OPD services:
CMS provides a list of the specific HCPCS codes that are included in the OPD Prior Authorization program.
| Question |
Description |
|---|---|
| WHO | Hospital OPD when rendering certain OPD services for Medicare beneficiaries that bill Medicare Part A can receive prior authorization. |
| WHAT | The hospital OPD (also known as the requestor) will be responsible to submit a PAR and all documentation for five groups of cosmetic services and their related services prior to the services being rendered to Medicare beneficiaries and before the provider can submit claims for payment under Medicare for these services. The five groups of hospital OPD services are blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation. |
| WHEN | The program will apply to hospital OPD services rendered on or after 7/1/2020. |
| WHERE | The program applies to all jurisdictions. |
| WHY | CMS believes PA 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 with no change in medical necessity documentation requirements. It is designed to ensure all relevant coverage, coding, payment rules and medical record requirements are met before the service is rendered to the beneficiary and the claim is submitted for payment. |
| HOW | Submit the PAR and all documentation. A UTN will be assigned with each PAR. An initial decision letter will be issued within ten business days of receipt of initial request. Resubmission notifications will be issued within ten business days of receipt of the resubmission request. |
The requester can submit an expedited review of the PAR if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function. However, if medical documentation does not support an expedited process, the request will be subject to the normal timeframe. We will make reasonable efforts to communicate a decision within two business days of receipt of an accepted expedited request.
For more information on coverage and documentation requirements, refer to:
Checklist for Blepharoplasty, Eyelid Surgery, Brow Lift and Related Services
(A52837)
| Code | Description |
|---|---|
| 15820 | Removal of excessive skin of lower eyelid |
| 15821 | Removal of excessive skin of lower eyelid and fat around eye |
| 15822 | Removal of excessive skin of upper eyelid |
| 15823 | Removal of excessive skin and fat of upper eyelid |
| 67900 | Repair of brow paralysis |
| 67901 | Repair of upper eyelid muscle to correct drooping or paralysis |
| 67902 | Repair of upper eyelid muscle to correct drooping or paralysis |
| 67903 | Shortening or advancement of upper eyelid muscle to correct drooping or paralysis |
| 67904 | Repair of tendon of upper eyelid |
| 67906 | Suspension of upper eyelid muscle to correct drooping or paralysis |
| 67908 | Removal of tissue, muscle, and membrane to correct eyelid drooping or paralysis |
| 67911 | Correction of widely-opened upper eyelid |
Checklist for Botulinum Toxin Injection
| Code | Description |
|---|---|
| 64612 | Injection of chemical for destruction of nerve muscles on one side of face |
| 64615 | Injection of chemical for destruction of facial and neck nerve muscles on both sides of face |
| J0585 | Injection, onabotulinumtoxina, 1 unit |
| J0586 | Injection, abobotulinumtoxina |
| J0587 | Injection, rimabotulinumtoxinb, 100 units |
| J0588 | Injection, incobotulinumtoxin a |
Checklist for Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
| CPT/HCPCS Code | Description |
|---|---|
| 15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy |
| 15847 | Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (list separately in addition to code for primary procedure) |
| 15877 | Suction assisted removal of fat from trunk |
Checklist for Rhinoplasty and Related Services
| CPT/HCPCS Code | Description |
|---|---|
| 20912 | Nasal cartilage graft |
| 21210 | Repair of nasal or cheek bone with bone graft |
| 30400 | Reshaping of tip of nose |
| 30410 | Reshaping of bone, cartilage or tip of nose |
| 30420 | Reshaping of bony cartilage dividing nasal passages |
| 30430 | Revision to reshape nose or tip of nose after previous repair |
| 30435 | Revision to reshape nasal bones after previous repair |
| 30450 | Revision to reshape nasal bones and tip of nose after previous repair |
| 30460 | Repair of congenital nasal defect to lengthen tip of nose |
| 30462 | Repair of congenital nasal defect with lengthening of tip of nose |
| 30465 | Widening of nasal passagebsp |
| 30520 | Reshaping of nasal cartilage |
Checklist for Vein Ablation and Related Services
| CPT/HCPCS Code | Description |
|---|---|
| 36473 | Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
| 36474 | Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
| 36475 | Destruction of insufficient vein of arm or leg, accessed through the skin |
| 36476 | Radiofrequency destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
| 36478 | Laser destruction of incompetent vein of arm or leg using imaging guidance, accessed through the skin |
| 36479 | Laser destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
| 36482 | Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance |
| 36483 | Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance |
What does this mean for the Part B Provider who will be performing the service in the hospital OPD?
As the performing provider, it is up to you to work with the staff at the hospital OPD department so that they may obtain the prior authorization for the services you want to perform in the OPD.
The PAR will require the medical necessity information which is typically documented in the patient’s medical record; documentation must fully support medical necessity for the service being performed. Since the physician typically holds the patient’s medical record, it is imperative that Part B providers work closely with the OPD to ensure they have all of the necessary information to obtain the PAR prior to rendering services which require prior authorization.
While only the hospital OPD service requires prior authorization, CMS reminds providers who perform services in the hospital OPD setting that claims related to or associated with these services will not be paid if the service requiring prior authorization is not eligible for payment. These related services include, but are not limited to, anesthesiology services, and physician services. Only associated services performed in the OPD setting are affected. These services, if performed without the required prior authorization, may be automatically denied or denied on a post-payment basis.
Decisions for PAR requests:
The hospital OPD and beneficiary will receive the decision letter from the MAC. Physicians or other practitioners who provide related services in the hospital OPD for the procedure requiring prior authorization may obtain a copy of the decision letter from the OPD.
Physician claims do not require a prior authorization number. The hospital OPD claim does require a unique tracking number which is provided upon the decision for prior approval.