In June 2020, the Centers for Medicare and Medicaid Services (CMS) implemented a prior authorization (PA) program for certain hospital outpatient department (OPD) services, for dates of service (DOS) on or after July 1, 2020, nationwide. CMS believes PA for certain hospital OPD services will ensure that:
- Medicare beneficiaries continue to receive medically necessary
- The Medicare Trust Fund is protected from improper payments, and
- The medical necessity documentation requirements stay unchanged for providers
As a condition of payment for DOS on or after July 1, 2020, a prior authorization request is required for the following hospital OPD services:
- Blepharoplasty, eyelid surgery, brow lift, and related services
- Botulinum toxin injections
- Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services
- Rhinoplasty and related services
- Vein ablation and related services
On May 13th, 2021, CMS updated the OPD prior authorizations program. Effective on or after July 1, 2021, prior authorization is required for two additional OPD services:
- Implanted Spinal Neurostimulators, and
CPT 63650: Implantation of spinal neurostimulator electrodes, accessed through the skin
- Cervical Fusion with Disc Removal Services
CPT 22551: Fusion of spine bones with removal of disc at upper spinal column, anterior approach, complex, initial.
- CPT 22552: Fusion of spine bones with removal of disc in upper spinal column below second vertebra of neck, anterior approach, each additional interspace.
When providers bill for implanted spinal neurostimulators, the only service that will require prior authorization is CPT code 63650, Percutaneous implantation of neurostimulator electrode array, epidura. In the OPD, providers who plan to perform both the trial and permanent implantation procedures using CPT code 63650 will only require prior authorization for the trial procedure, not the permanent implantation surgery. However, when the trial procedure is done 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.
Also, both CPT codes 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling and 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver, are being temporarily removed from the list of OPD services requiring prior authorization.
These codes are effective on and after July 1, 2021. Do you market a drug, medical device, diagnostic, or biologic with specific PA requirements? Do your accounts consider the requirements and process to be onerous? Are your accounts aware of the necessary documentation requirements? The GIRS InContact Reimbursement Hotline® service can educate your accounts and assist them with PA successfully to improve patient access.
Disclaimer: The information in this blog is based on payer information which is dynamic. It is accurate at the time of posting but should not be construed to be reimbursement or legal advice. CPT® is the trademark of the American Medical Association (AMA).
Sources:
- https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services
- opd-services-require-prior-authorization.pdf (cms.gov)
- https://www.govinfo.gov/content/pkg/FR-2019-11-12/pdf/2019-24138.pdf
- https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00227906
About GIRS
For more than 19 years, GIRS has been assisting medical technology manufacturers with their market uptake and reimbursement strategies so that patients can have access to the care that they need. To implement successful market access strategies, the GIRS Value Discovery Landscape Assessments® team and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, email us at info@girsinc.com or call us at 901-834-9119.