May 26, 2021
Since 7/1/20, when CMS initiated a requirement for specific procedures to be prior authorized, we have sent out two KZAlerts about the PA process
CMS says the PA policies are to ensure Medicare patients receive “necessary care” and “reduce unnecessary increases in the volume” of covered outpatient services.
Now, there’s more! Beginning July 1, CMS will require prior authorization for two NEW service categories:
- Cervical fusion with disc removal [CPT 22551 and +22552 only],
- Implanted spinal neurostimulators [CPT 63650 only]
The good news is that CPT 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver) and 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver) were temporarily removed from the list of Hospital Outpatient Department (HOPD) services that require PA.
What location of service requires the PA?
Remember, the services must be performed in the HOPD to require a PA. What if you performed the procedure in your office (place of service 11) or ambulatory surgery center (place of service 24)? CMS does NOT require prior authorization for these services when provided in POS 11 or 24.
Who obtains the PA?
CMS says: The HOPD, the physician, or another third party on behalf of the HOPD is responsible for submitting the PA request and all necessary documentation. However, if the service was not prior authorized, then no claims will be paid.
KZA says: Do it yourself. Don’t rely on someone else to obtain the PA – your payment is at risk.
What services require PA?
CMS lists the following services, performed in a HOPD (POS 22), as requiring PA:
- Botulinum toxin injection
- Vein ablation
- Cervical fusion with disc removal
- Implanted spinal neurostimulators
The full list of CPT codes requiring PA can be found here – check it out because you will be surprised at some of the codes:
How do you operationalize the CMS PA process in your practice?
Medicare’s operational guide for PAs can be found here: https://www.cms.gov/files/document/opd-operational-guide.pdf
Also, you’ll want to look at your Medicare Administrative Carrier’s (MAC) website for information. For example, here is a link to the Novitas site:
CMS HOPD website:
(All websites accessed 5/25/21)