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Medicare to Require Prior Authorization for Certain Outpatient Department Services Starting July 1, 2020

Medicare to Require Prior Authorization for Certain Outpatient Department Services Starting July 1, 2020

In the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (2020 OPPS Final Rule), the Centers for Medicare and Medicaid Services (CMS) established a prior authorization process and requirements for certain hospital outpatient department (OPD) services in order to help control unnecessary increases in the volume of these services.

Beginning July 1, services requiring prior authorization will include vein ablation, blepharoplasty, botulinum toxin injections, panniculectomy and rhinoplasty. Otolaryngology services impacted include:

  • 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
  • 20912 Nasal cartilage 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
  • 30520 Reshaping of nasal cartilage
  • 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
  • 64612 Injection of chemical for destruction of nerve muscles on one side of face

The full list of HCPCS codes requiring prior authorization is available on the CMS website. This prior authorization requirement is limited to services rendered in the hospital outpatient department only.

Regional Medicare Administrative Contractors (MACs) will administer the prior authorization program which consists of developing the approval criteria, processing the authorization requests, and notifying the requestors and patients of the results. There is no specific form to request prior authorization; however, MACs may make cover sheets or other templates available for voluntary use. Members are encouraged to check their local MAC website for upcoming webcasts and resources on this new process. Prior authorization requests for dates of services beginning July 1, 2020, will be accepted by MACs starting June 17, 2020. The standard review timeframe is ten business days from the date the prior authorization request is received. If this timeframe could seriously jeopardize the life or health of the beneficiary, a provider can request an expedited review of two business days.

The AAO-HNS encourages members performing these services for Medicare patients to review the CMS Prior Authorization Process for Certain Hospital Outpatient Department Services presentation slides, OPD Operational Guide, and Frequently Asked Questions PDF on the CMS Prior Authorization website for additional information and guidance on the program.

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