Medicare recently finalized a plan that will require hospitals to obtain prior authorization before performing certain outpatient procedures. Understanding these changes will be critical to avoid unnecessary denials beginning on July 1, 2020.
The new prior authorization rules, which were outlined in the 2020 Medicare Hospital Outpatient Prospective Payment System (OOPS), are primarily for services that are sometimes performed for cosmetic purposes and have been identified by the Centers for Medicare and Medicaid Services (CMS) as being at-risk for incorrect payment due to medical necessity concerns.
The prior authorization final rule was published in the Federal Register on Nov. 12, 2019, in Section XIX under “Prior Authorization Process and Requirements for Certain Hospital Outpatient Department (OPD) Services.”
Masking cosmetic procedures
According to the rule, CMS conducted an analysis of over 1 billion claims relating to outpatient department services (OPD) dating from 2007 to 2017. The agency determined that utilization volume increased significantly during that period, from approximately 90 million to 118 million. In addition, the Medicare allowed amount for OPD more than doubled, from $31 billion in 2007 to $65 billion in 2017.
To reduce improper outpatient claims, CMS specifically targeted Medicare cosmetic surgical procedures that may be combined with, or masquerade as, therapeutic services. CMS’ analysis indicated the following outpatient procedure categories had higher-than-expected volume:
- Botulinum toxin injections
July 2020 deadline
Prior authorization for the specified list of procedures found under these categories (see below) must be obtained for services performed on or after July 1, 2020. In theory, the authorization process should take no more than 10 days. Either the physician or the hospital may submit the request for prior authorization, but the hospital will remain ultimately responsible for ensuring that authorization is obtained prior to the surgical procedure.
To help prevent unnecessary denials, be sure your staff is fully aware of the specific procedures that now require prior authorization. Be sure to watch for news from your local Medicare Administrative Contractor (MAC) as the July 1 implementation date approaches because the MACs will be responsible for organizing the authorization request process.
Table 65: Proposed List of Outpatient Services That Would Require Prior Authorization 
|Code||(i) Blepharoplasty, Eyelid Surgery, Brow Lift, and Related Services|
|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 dropping or paralysis|
|67908||Removal of tissue, muscle, and membrane to correct eyelid dropping or paralysis|
|67911||Correction of widely opened upper eyelid|
|Code||(ii) Botulinum Toxin Injection|
|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|
|J0587||Injection, rimabotulinumtoxinb, 100 units|
|Code||(iii) Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy), and Related Services|
|15830||Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy|
|15847||Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g. Abdominoplasty) (includes umbilical transposition and fascial plication) (list separately in addition to code for primary procedure)|
|15877||Suction assisted removal of fat from trunk|
|Code||(iv) Rhinoplasty, and Related Services|
|20912||Nasal cartilage graft|
|21210||Repair of nasal or cheek bone with bone graft|
|21235||Obtaining ear cartilage for grafting|
|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 passage|
|30520||Reshaping of nasal cartilage|
|Code||(v) Vein Ablation and Related Services|
|36473||Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance|
|36474||Mechanochemical destruction of insufficient vein or 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 desctruction of insufficient vein of arm or leg, accessed through the skin using imaging guidence|
|36478||Laser desctruction of incompetent vein of arm or leg, accessed through the skin|
|36479||Laser desctrustion 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|
Your AR specialists
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- Federal Register / Vol. 84, No. 218 / Tuesday, November 12, 2019 / Rules and Regulations. Pages 61450-61451.
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