The Centers for Medicare & Medicaid Services (CMS) is updating its nationwide requirements for certain hospital outpatient department (OPD) services as part of the 2021 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS -1736-FC). Starting on July 1, 2021, the following hospital OPD services will require providers to request prior authorization as a condition of payment:
- Cervical fusion with disc removal
- Code 22551: The fusion of spine bones with removal of disc at upper spinal column
- Code 22552: The fusion of spine bones with removal of disc in upper spinal column below the second vertebra of the neck
- Implanted spinal neurostimulators
- Code 63650: The implantation of spinal neurostimulator electrodes, accessed through the skin
These two services will be added to the list of existing prior authorization services, which include: blepharoplasty, botulinum toxin injection, rhinoplasty, panniculectomy, and vein ablation.
The new rule is designed to ensure that Medicare patients continue to receive necessary care, while also reducing unneeded increases in the volume of these services and preventing improper Medicare payments.
Under the new requirements, the hospital OPD, the OPD physician, or another third party on behalf of the OPD must submit a request with required documentation before the service is performed and before the claim is submitted for payment to verify that all Medicare prerequisites are met.
After reviewing the authorization request, the Medicare Administrative Contractors (MAC) will issue a provisional affirmation or non-affirmation within ten business days of receipt. Providers can request an expedited review in cases where the Medicare beneficiary’s life, health, or ability to function is in danger. Requesters can revise and resubmit non-affirmed requests an unlimited number of times.
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