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Prior authorization (PA) program for certain hospital outpatient department (OPD) services – frequently asked questions (FAQs)
Last Modified: 11/19/2024
Location: FL, PR, USVI
Business: Part A, Part B
1Q: The patient’s surgery is scheduled in 7 days. Can I submit my prior authorization request (PAR) now?
1A: A PAR should be submitted prior to scheduling the patient for the surgery. Providers should not schedule surgery until the affirmed decision letter and unique tracking number (UTN) are received for a PAR. Once a PAR is received, a decision will be made within ten business days. Do not submit an expedited PAR unless the beneficiary’s life or functional status is in jeopardy.
2Q: If the hospital outpatient department (HOPD) initiates the authorization process, can the performing physician/clinician submit clinical/medical documentation directly to First Coast separately?
2A: No, each submission will be reviewed separately. The submissions should be sent together, but the physician can submit the PA on behalf of the HOPD. The HOPD will be using the unique tracking number (UTN) assigned.
3Q: Can you please clarify the PAR process for Medicare secondary payer (MSP)?
3A: For MSP situations, the requester submits the PAR with complete documentation as appropriate prior to providing the service.
4Q: The PAR must be submitted prior to the procedure, correct?
4A: Yes, the PAR needs to be done prior to performing the procedure. Retroactive authorization is not applicable. Please remember that the PAR is valid for 120 days from the day the decision is made.
5Q: How do you obtain PA for physicians billing and doing procedures at an OPD?
5A: The PAR only applies to the HOPD.
6Q: How do we fax photographs?
6A: We recommend submitting the PAR through the Secure Provider Online Tool (SPOT) portal, which allows for color images and sharper quality than a fax.
7Q: How do we go about signing up for esMD to submit PA documentation online?
8Q: If a surgery date is changed or canceled, can we request an extension of the 120 days?
8A: No. If a surgery will go past the original 120-day PAR, a new PAR would be required.
9Q: Can you have overlapping PAR requests?
9A: No, if your new date of service request would overlap the 120-day period already approved, then you would need to contact the customer contact center to expire the previous PAR.
10Q: Is the CMS certification number (CCN) the Provider Transaction Access Number (PTAN) for the facility?
10A: Yes, the CCN is the PTAN for the facility.
11Q: All the documentation for the PA originates with the ordering surgeon’s evaluation and records. The facility will not encounter the patient until the date of surgery, so it does not seem logical to place the onus of documentation on the facility prior to seeing the patient. Why isn't the surgeon the one to request the PA, with the requirement to include the facility where the surgery will take place?
11A: The guidelines provided are a CMS directive. The provider (surgeon) can submit the PAR on behalf of the HOPD. However, the decision letter will be sent to the HOPD and the UTN provided is reported only on the UB04 claim (not the CMS-1500 claim form) or electronic equivalent.
12Q: Is there a plan to expand PA requirements to include other procedures/services in the future aside from those outlined in the webinar?
12A: First Coast receives direction from CMS. Please contact CMS for updates regarding future plans.
13Q: As it relates to the prior authorization program, has anything changed for cosmetic surgeries?
13A: If submitted without PA, an advance beneficiary notice (ABN) will be needed to allow payment recoupment from the beneficiary. Otherwise, medical necessity requirements have not changed.
14Q: Does the PA program apply to ambulatory surgical centers (ASCs)?
14A: The PA program does not apply to ASCs.
15Q: How far in advance are we able to submit a prior authorization request from the anticipated date of service?
15A: A provisional affirmation is valid for 120 days from the date the decision was made. If the date of service is not within 120 days of the decision date, the provider will need to submit a new prior authorization request.
A best practice would be to submit a PAR at least two weeks prior to the expected date of the procedure.
Note: Since CMS has mandated prior authorization for certain hospital OPD services as a condition of payment, when a PAR is received and it has been determined that the related procedure has already been rendered, the PAR will be non-affirmed.
16Q: How do we obtain the PTAN (or CCN) for the hospital or the physician that is required to be reported on the PAR?
16A: Hospitals and physicians need to communicate to coordinate care. Hospital (facility) and provider (physician) NPIs and CCNs/PTANs are required to be reported on the PAR. It may be necessary for the facility and/or provider to contact one another to obtain the NPI and/or PTAN/CCN. CMS does have a
Medicare Inpatient Hospital Look-up Tool 
to look up IPPS hospital facilities. You can search by name and location to get the PTAN/CCN and vice versa. The
NNPES NPI Registry can be used to look up facility and provider NPIs.
17Q: What should I do if I am having trouble getting my fax to go through?
17A: Ensure you are using the correct fax number (855-815-3065) and if the fax is not going through call the Prior Authorization Contact Center at 855-340-5975 available Monday – Friday, 8 a.m. – 6 p.m. ET.
18Q: What meets expedited criteria for all prior authorization services?
18A: A request should only be expedited if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function.
1Q: if the authorization is obtained by a physician's office, will the PA cover both hospital/facility and physician? Or will the hospital have to obtain its own PA?
1A: It is the expectation that the HOPD will receive the PAR decision, regardless of who requests the PA.
2Q: How do you follow up on PA after it’s been submitted - via phone or fax or electronic?
2A: Contact the PA customer service number to check the status of your request at 855-340-5975. Please remember processing time is 10 business days for PARs, and 2 business days for valid expedited requests.
• Note: Effective for PARs received January 1, 2025, and after the decision letter will be issued within 7 calendar days.
3Q: If the place of service (POS) changes from 19 (off-campus) or 22 (on-campus) to 21 (inpatient) due to a clinical condition and a notice of admission is sent, how will that impact the authorized claim?
3A: If the service is changed to inpatient hospital, the PA would not be necessary because the type of bill (TOB) for the hospital claim would change from TOB 13X to TOB 11X and the PA only applies to TOB 13X.
4Q: To be clear, does the hospital get the PA or does the surgeon’s staff get the PA?
4A: The PA applies to the hospital outpatient department. However, the surgeon may request the PA on behalf of the HOPD. The PA decision letter will only go to the HOPD and the beneficiary, not the surgeon.
5Q: When a PAR is determined as “non-affirmed,” do we need to allow 120 days to pass before resubmitting another request or are we able to resubmit as soon as we get the decision?
5A: A PAR may be resubmitted as soon as you receive the non-affirmed decision.
6Q: When resubmitting a PAR, can it be expedited due the date of service for the procedure?
6A: No, a request should only be expedited if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function.
7Q: If the procedure did not meet the guidelines for approval, and if we obtain the information, can we resubmit for authorization? What is the timeframe for response to this resubmission?
7A: Yes, you can do a PAR resubmission. You will receive a determination within 10 business days of a PAR resubmission. There is no limitation on how many PARs that can be submitted to obtain an affirmation.
• Note: Effective for PARs received January 1, 2025, and after the decision letter will be issued within 7 calendar days.
8Q: If a PAR is non-affirmed, can a peer-to-peer review be conducted or does a new PAR need to be submitted for the same service?
8A: A peer-to-peer review would be considered on a case-by-case basis. No matter what, a resubmission is still needed.
9Q: What happens when a procedure has been scheduled but PA has not yet been received OR the corresponding authorization response is “non-affirmed”? Last Modified: 10/26/2020
9A: As explained in the
CMS OPD Operational Guide , if a service requires PA, then submitting a PAR is a condition of payment. Claims for HCPCS codes subject to required PA submitted without a PA determination and a corresponding UTN will be automatically denied.
Recommendation: Do not schedule procedure(s) until affirmation has been received. 10Q: I submitted my PAR last week, but I have not received a response. Should I submit a new PAR?
10A: Sending in a duplicate request for the same procedure(s) and date of service is not recommended. First Coast has up to 10 business days to review the PAR and issue a decision. Submitting another PAR for the same procedure(s) and date of service is not necessary as this would be a duplicate.
• Note: Effective for PARs received January 1, 2025, and after the decision letter will be issued within 7 calendar days.
11Q: For a resubmission PAR, what needs to be submitted?
11A: For a resubmission PAR, be sure to include the following:
• The initial PAR cover sheet
• All documentation from the original submission
• Any additional information/documentation
• Does the UTN use the alpha O or the numeric 0?
• The UTN only uses the number 0 (zero) and never the letter O.
• What are acceptable signatures?
• What do I do if I see the signature and you do not?
•
Contact your electronic medical record (EMR) vendor, as signatures must be on all documentation submitted for review.
15Q: My PAR was dismissed because it said my photos were illegible. I sent the photos via fax. Why were the photos not acceptable?
15A: The submission of photos via fax or mail is not ideal due to the lack of clarity. Faxed photos are only black and white and do not have sufficient detail required to support the PAR. We highly recommend using the
Secure Provider Online Tool (SPOT) for submitting photos. SPOT will provide the best quality and clarity for photos since they can be submitted in color.
1Q: How many days’ notice will I receive before I switch from Prior Authorization Request (PAR) submissions to an exemption cycle?
1A: MACs will provide a 60-day notice prior to any transition period, continuation, or withdrawal from exemption.
2Q: I received a letter stating that I am starting exemption. What do I do now?
2A: PARs should not be submitted and will be rejected during the exemption cycle. Claims submitted while on exemption will not require a unique tracking number (UTN). Please follow the instructions in the exemption notification letter.
3Q: I received a letter stating I am now withdrawn from exemption? What do I do now?
3A: Providers may resume submitting PARs beginning December 18 for dates of service on or after January 1. PARs will be required starting January 1. Your PAR affirmation rate will be monitored for the next exemption cycle.
4Q: Why are my PARs being rejected while on exemption?
4A: PARs are not required while a provider is on exemption, therefore any PAR submitted will be returned with a rejection decision. PARs should not be submitted for the purpose of obtaining a rejection letter for medical record keeping.
5Q: How do I bill PA claims without a UTN during the exemption period?
5A: PA services that were performed during the exemption period should follow the same billing practices used prior to the start of the exemption period. Applying previously used UTNs or invalid UTNs may delay processing of your claim.
6Q: Toward the end of the exemption cycle, the MAC conducts a 10-claim post-payment review. How are the claims selected?
6A: The 10-claim sample is based on claim dates of service during the exemption period. This means that the claims selected will be from the timeframe in which you were exempt and are randomly selected.
7Q: Does the exemption process exempt providers from all OPD PA services?
7A: Yes. If you receive a notice of exemption, it applies to all services under the OPD PA program. If CMS adds new procedures to the Prior Authorization Program during the exemption cycle, they will be included in the exemption process for the provider.
8Q: If an exempt provider submits a PAR on December 21 but it is non-affirmed, and the provider then becomes exempt on January 1, does the provider need to resubmit the PAR? Will that resubmission reject if it is past the exempt start date? 8A: You do not need to resubmit if the procedure is performed after the start of the exemption period. If you do resubmit the PAR on or after January 1, it will be rejected.
9Q: If I am an exempt provider, but during ADR review, it is determined that I no longer meet the requirements to remain exempt, when do I need to resume submitting PARs and begin adding a UTN to my claims? 9A: MACs will start accepting PARs from providers who are withdrawn from exemption on December 18. Claims with dates of service on or after January 1 require a UTN.
10Q: What does it mean to opt-out of exemption?
10A: CMS has established a rule that allows providers to remain in the standard cycle and continue to submit PARs. Providers will receive a notice of exemption if they achieved a greater than 90% PAR affirmation rate. An opt-out form will be included with the exemption notification letter. The form must be submitted to the MAC by November 30. Late requests will be rejected.
11Q: What are ADRs?
11A: Additional Documentation Requests: ADRs are issued based on a specific claim submitted to your MAC. The ADR will specify the beneficiary and date of service and include a list of suggested documentation for a particular service to submit to your MAC that would support payment of your claim.
12Q: How many claims will be selected for ADR review?
12A: Your MAC will randomly select 10 post-payment claims for the ADR review.
13Q: What is the ADR timeline?
13A: The first ADR for exempt providers will be sent on August 1. The provider has 45 days to submit the documentation and the MAC has 45 days to review the documentation and make a determination. Notification of withdrawal will be sent out no later than November 2.
August 1st |
Exempt providers will receive an ADR for a random ten claim post-pay review. Providers have 45 days to submit documentation. MACs have 45 days to review. |
November 2nd |
MACs will send notification letters for either continued exemption or withdrawal from exemption. Providers must achieve a greater than 90% claim approval rate with post pay claim review to continue with exemption. |
December 18th |
Providers who received a notification of withdrawal from exemption may submit PARs. |
1Q: Is the SPOT available as an option to submit PA requests?
1A: The SPOT is available for PAR submissions as of June 17, 2020.
2Q: Regarding submission of the PAR through SPOT, is there a step by step guide on submitting authorization requests via SPOT?
2A: Instructions will be available in the
SPOT User Guide. SPOT submission is available as of June 17, 2020.
Note: see Prior authorization coversheet instructions for additional guidance.
3Q: Will SPOT provide status on the PA or must you call for status?
3A: Once the request is successfully submitted via SPOT, a confirmation notification will generate. Once a determination is made for the PA, a decision notification is sent to the provider via the SPOT. However, providers may call the PA customer service number to check the status of their request(s). The number is 855-340-5975. (Note: the PTAN, NPI, and last 5 digits of the TAX ID of the hospital OPD must be provided for authentication when you call.)
4Q: Will decision letters be available on SPOT?
4A: Yes, decision letters will be available in SPOT.
5Q: If we submit the PAR via the SPOT portal will the response still be by fax?
5A: No, if the PAR is submitted through the SPOT portal, the decision notification will be through the portal only.
1Q: If a Part B claim is submitted without a UTN, will that be denied or would this only apply to Part A claims?
1A: Currently, only the Part A claim requires the addition of the UTN. The UTN does not apply to the Part B claim and, if listed on the Part B claim, the claim will reject.
2Q: If the PAR for the hospital was non-affirmed and the hospital submits a claim, the claim will be denied. Will this denial only apply to the hospital’s claim or will it apply to the surgeon’s claim as well?
2A: We would not expect to receive a claim from the surgeon if the HOPD PAR was non-affirmed. CMS clarified claims related to or associated with services requiring prior authorization as a condition of payment will not be paid, if the service requiring prior authorization is not also paid. These related services include, but are not limited to, services such as anesthesiology services, physician services, and/or facility services. Only associated services performed in the OPD setting will be affected. Depending on the timing of claim submission for any related services, claims may be automatically denied or denied on a post-payment basis.
3Q: With non-affirmation and claim submission, appeal rights are afforded. Can the appeal be overturned by making a case for medical necessity?
3A: Yes, appeals are subject to medical necessity.
4Q: What is the field locator on the UB-04 and the loop/location for electronic billing where the UTN for the PA should be reported on a claim?
4A: For the UB-04, submit the Form Locator 63:
Report UTN on the same line (A, B, C) that Medicare is shown in Form Locator 50 (Payer Line A, B, C)
UTN should begin in position 1 of Form Locator 63
For electronic claims, submit the UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment:
• REF01 = "G1" qualifier and REF02 = UTN
• This meets the requirements of the ASC X12 837 Technical Report 3 (TR3)
5Q: Can you provide more clarification on the claim submission deadlines?
5A: The UTN is valid for 120 days from date of the decision letter. The service must be performed within the 120-day range specified in the decision letter. If the date of service (DOS) is outside the 120 days, then the UTN is no longer valid and a new PAR is required.
The 120 days for the UTN does not impact claim timely filing. Claims must be filed within one year of the actual DOS.
6Q: If the PAR is denied and the patient signs the ABN, will everything be paid except for the procedure itself and leave the patient responsible for the cost of the procedure itself?
6A: If not listed on the ABN, the beneficiary would not be liable.
7Q: How do you bill PA on a CMS-1500 form? How do you submit for a physician bill?
7A: Continue to bill as normal, until further CMS clarification is given. It is expected that if the HOPD receives a non-affirmation that they would notify the physician so that the physician can make an informed decision regarding the POS they plan to perform the service. CMS recently confirmed that any claim associated with or related to a service that requires PA for which a claim denial is issued would also be denied. This includes but is not limited to services such as anesthesiology services, physician services, and/or facility services.
8Q: Does the UTN from the decision letter need to be documented in the chart note AND the claim or just the claim?
8A: The UTN only needs to be documented on the claim.
9Q: In the event a PAR is not obtained, is the provider able to appeal the denied claim?
1Q: Can facet joint interventions be performed under ultrasound guidance?
1A: No, only CT and fluoroscopic guidance.
2Q: Can a patient receive facet injections in both cervical/thoracic and lumbar spinal regions during the same session?
2A: No, interventions are limited to one spinal region per session.
3Q: Can a provider do four injections on same side in one session?
3A: No, the policy allows a maximum of two unilateral or four bilateral per session (one spinal region allowed per session with 1-2 levels unilateral or bilateral per session).
4Q: Will a facet joint injection performed with a biological added to the injectant still be covered?
4A: No, if facet joints are injected with biologicals or other substances not designated for this use the entire claim will deny.
5Q: If a patient had radiofrequency ablation (RFA) three years ago and has not been seen since for this complaint, and now returns with similar symptoms, can a provider proceed with repeat RFA?
5A: Repeat facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least 6 months and at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale.
6Q: What if a beneficiary needs to reverse anticoagulation before proceeding with facet joint diagnostic injections and the provider feels that a two-week delay between injections is not in the best interest of the beneficiary?
6A: Rationale for performing the diagnostic injection at a shorter interval must be clearly documented in the medical record. The provider should amend the KX modifier (indicating that the service is medically necessary and meets coverage criteria) and exemption may be considered on an individual basis.
7Q: Can RFA be repeated in 6 months?
7A: Yes, if the patient has had two confirmatory diagnostic blocks resulting in at least 80% pain relief and the previous RFA resulted in at least 50% improvement in pain for at least six months, the patient may proceed with repeat RFA up to two times in a rolling 12 months if indicated.
8Q: Is there a limit of 2 levels per region at each session? What if a patient needs injections at 3 levels in the same region?
9Q: Can RFA be performed on a surgically spinal fused level?
9A: RFA cannot be performed after anterior lumbar fusion (ALIF). Posterior fusions may be treated as facet joint pain is inflammatory and not based on instability, therefore, the restriction for facet joint procedures at fused posterior spinal segment was removed. Facet joint injections may be performed at levels previously treated by anterior cervical discectomy and fusion.
10Q: How do we bill for T12-L1 level? Does this count as two regions?
10A: No, it does not count as two regions. Use CPT code 64490 for T12-L1 facet injections for diagnostic or therapeutic interventions, and CPT code 64633 for any T12-L1 neurolytic interventions. For unilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use CPT codes 64490 and 64494 once. For bilateral paravertebral facet injection of the T12-L1 and L1 – L2 levels or nerves innervating that joint, use CPT code 64490 with modifier 50 and CPT code 64494 with modifier 50.
11Q: For covered spinal regions, is it cervical/thoracic as one region and lumbar/sacral as the other?
Region: The segments of the back involved will be defined in this policy as two regions:
1. Cervical/Thoracic region = C1-C7/T1-T12
2. Lumbar/Sacral region = L1-L5/S1-S5
12Q: Can facet procedures be performed under sedation? Is light sedation or moderate without anesthesia allowed?
12A: Facet joint interventions are typically only performed with a local anesthetic. There is no definition for “light sedation”*. If indicated, minimal sedation can be given to relieve anxiety as long as it has no or very little effect on patient awareness. The use of moderate sedation, deep sedation and general anesthesia are not reasonable and necessary. Reporting of these services together may trigger focused medical review.
13Q: Are the limitations of two diagnostic MBB's per spine region for all spine regions for the twelve rolling months?
13A: Two diagnostic medial branch blocks may be performed per session. If the patient fails to respond and there is concern that the pain generator was not identified, two additional blocks can be performed at a different level in a separate session. The total number of diagnostic blocks for all levels within a spinal region is four in a rolling twelve months. Only one spinal region can be treated in the same session.
14Q: Is the expectation that RFA is performed bilaterally in order to be able to do the procedure within the limit of two sessions per twelve months?
14A: It can be performed unilaterally or bilaterally in the same session depending on what is clinically indicated. The session limit is two sessions per twelve months regardless of whether it was performed unilaterally or bilaterally.
15Q: What if the patient has degeneration of the spine as a natural process, there could be more than one pain generator or pain source?
16A: We agree. Radiographically, degeneration can occur throughout the entire spine as a result of aging and natural process. The presence of degeneration does not equate to disease or pain source. The objective is to diagnose the sources of pain and optimize treatment to that specific location. Approaches of multiple injections including facet, epidural and others at multiple levels in an effort to capture the pain generator is not acceptable and exposes the patients to unnecessary risk. The objective of this policy is to identify if the facet joint is indeed the source, and focus intervention to the specific pain generators.
17Q: If a provider does an MBB injection and there is little to no improvement, can they then do IA facet injections?
17A: No, because diagnostic injections will have been considered negative. The LCD clearly defines the degree of improvement necessary to proceed to each next step. Therapeutic IAs still require proof of two preceding, successful diagnostic injections. Per Section B-1 of LCD L34893 it states to be considered medically reasonable and necessary, the patient has had 2 medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used)
18Q: Is documentation for both a pain and a disability scale required at baseline?
18A: Pain scales alone can be utilized, but if the provider wishes to use a disability scale for establishing indication for follow up procedures, they must have already documented a baseline disability scale. Repeat RFAs now require proof of 50% improvement in measured pain as well as 50% improvement in measured functional ability. Per Section C-2 of LCD L34892, “Repeat 6 facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least 6 months and at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale.
19Q: If a patient has an RFA, can they restart diagnostic injections if they had at least 50% improvement for at least six months, if they start having pain again? Or can they only have a repeat RFA?
19A: Yes, if there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated. Otherwise, repeat diagnostic procedures are not required in the setting of a previously successful RFA.
20Q: Why should small doses of steroid not be used in diagnostic blocks, as they can provided relief from local inflammation?
20A: The policy does not restrict the injectant to local anesthetic alone but if steroids are used consideration for a longer duration between diagnostic injections should be made to avoid risk of higher systemic doses of steroids.
21Q: It is extremely highly unlikely for people to have strictly facetogenic pain as most of the patients have multiple issues. We do the diagnostic not only to confirm facet as pain generator and also it proves that radicular component is not the true pain generator. Hence how can we purely consider just facet pain as the only indicator for diagnostic block?
21A: We agree that multiple etiologies can be present and challenging to identify the specific pain generator. For patients who there is a high clinical suspicion for facet joint pain and meet the four criteria for diagnostic injections these injections may also be negative ruling out a facet source. This may also aid in the differential diagnosis of other etiologies. That is why within the policy they are considered diagnostic.
22Q: How will it work for patients that had their diagnostic injections prior to effective date of policy (not submitted with the KX modifier) but then coming in for a therapeutic injection or RFA after 4-25-2021? Will the documentation be requested for review prior to payment or is there some sort of grace period?
22A: The count’s which go into the rolling 12-month edit do not start until the effective date of the new policy. Therefore, older claims do not accrue to the count and will not cause an edit to occur. We do not plan pre-payment review at this point.
23Q: Is the KX modifier to be submitted along with the claim submission or is it to be submitted during review of medical necessity on appeal?
23A: The KX modifier should be submitted with the claim.
24Q: Modifier KX is not required to be submitted on therapeutic injection claims- is this statement correct?
24A: Yes. it is anticipated that there will be very few therapeutic injections. If there is a therapeutic injection, the KX modifier is not needed but the additional documentation requirement is to explain why the patient is not a candidate for RFA.
25Q: Is it necessary to use the KX modifier in the ASC?
25A: KX modifier should be used for ALL diagnostic injections regardless of site of service.
26Q: If a patient still wants 3 levels in the same region injected, can we bill the first 2 levels to Medicare and then bill the patient for the 3rd level if they sign an ABN?
27Q: How should the provider submit requests for bilateral procedures?
27A: Each of the participating procedure codes for facet joint intervention have a Medically Unlikely Edit (MUE) of 1.
When the procedure is performed bilaterally at the same level, report 1 unit of the primary code with modifier -50. Please indicate the levels/laterality/the use of any modifiers on the coversheet submitted with each prior authorization request.
1Q: Are private physicians required to submit a PA for Botox in their office?
1A: No, a PA is required by the HOPD when the service is going to be provided in the HOPD. The PA applies to the 13X TOB.
2Q: Will we need to submit a revised authorization post-procedure if we go over the number of units for Botox?
2A: If a claim is submitted with more units than specified on the PAR, then the claim will be denied.
3Q: Can you confirm that Botox J-codes only need prior authorization if they are used in conjunction with Current Procedural terminology (CPT®) codes 64612 or 64615?
3A: Yes; prior authorization is only for J-codes submitted with CPT codes 64612 or 64615.
4Q: What will happen to my claim if it is only billed with an administration code or the drug code?
4A: Claims will now Return to Provider (RTP), that are billed with the drug code without an administration code or if claims are billed with the administration code without the drug code.
5Q: Is there a list of diagnosis codes covered by Medicare for Botox?
5A: The PA program is currently based only on procedure codes and not diagnosis codes. However, we have a local coverage determination (LCD) and subsequent
LCD article on billing and coding for Botulinum Toxins (A57715) 
that provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials.
6Q: Botox can be injected per label every 12 weeks and a PA is good for 120 days. Can a provider bill for two separate dates of service under one PAR/UTN request?
6A: No, only one DOS may be authorized per PAR.
7Q: Would it be your recommendation that all botulinum toxin services be submitted for PAR regardless of the indication, since there is not a formal medical necessity policy?
8Q: If Botox is being given in the provider’s office and billed using provider-based billing (performed in the office, but billed as an outpatient department of the hospital) it would require a PA, correct?
8A: The PA is required for the HOPD billing a TOB 13X. For provider-based billing, the provider/physician will bill the claim on the 1500 claim form with the POS 19 (off-campus) or 22 (on-campus) while the HOPD will bill the claim on the UB-04 with a TOB 13X.
9Q: Do we need approval for the CPT codes 64644 and 64616 with the Botox J0585/J0588?
10Q: If a Botox injection will be given in the operating room (OR) for an outpatient surgical procedure, will this require a PAR?
10A: The PAR is required if the service is performed in an HOPD billing a TOB 13X.
1Q: Does septoplasty (CPT code 30520) need a PA when done alone, or does it require a PA if being done in conjunction with rhinoplasty?
2Q: If a patient has a history of a previous rhinoplasty, should a primary or secondary code be reported?
2A: Primary procedure codes should be used for an initial intervention. Secondary procedure codes should be reported if the patient has undergone the same procedure in the past.
1Q: Your panniculectomy LCD states 18 months after bariatric surgery. No other Medicare administrative contractor requires that long a timeframe. What was the basis of that timeframe? Is it absolute? What if weight stable for 6 months and it is 12 months after surgery?
1Q: Are PA requests required for radio frequency ablations unrelated to a diagnosis of deep vein thrombosis (DVT)?
2Q: How many units should be requested for bilateral services, 1 or 2?
2A: Every code is specific to one; however, there are modifiers that impact the claim. Please refer to the Current Procedural Terminology (CPT) manual.
1Q: Are photographs required for review of Blepharoplasty and related services?
2Q: Does an interpretation of the visual field testing need to be submitted for review?
3Q: How many units should be requested for bilateral services, 1 or 2?
3A: Every code is specific to one; however, there are modifiers that impact the claim. Please refer to the Current Procedural Terminology (CPT) manual.
1Q. When is conservative treatment required?
1A: Conservative treatment is tailored to the beneficiary's care plan. Conservative treatment may consist of, but is not limited to: injections, medications, physical therapy or occupational therapy, assistive device use. Each request is reviewed individually to determine if medical necessity is met. Please refer to our
LCD: L39799 Cervical Fusion.
2Q: Is an ACDF at C3-C4 considered one level, or two?
2A: Procedure codes 22551 and 22552 each represent an intervertebral disc space (the area in between two vertebra). As such, fusion of C3-C4 would appropriately be coded as one level with one unit of procedure code 22551. Each additional interspace would be reported with procedure code 22552.
3Q: Will ACDF be considered if the patient has canal stenosis on imaging but is otherwise asymptomatic?
3A: No, asymptomatic myelopathy (regardless of severity on imaging findings) is considered not reasonable and necessary for the decompression of cervical canal stenosis.
4Q: Is imaging required?
4A: Yes, for all indications, imaging must be submitted in the form of an MRI or CT. Biopsy, bone aspirate, and x-rays may also be indicated depending on the indication (i.e., Section C).
1Q. When should a PAR be submitted for a permanent implanted spinal neurostimulator?
1A: Providers who plan to perform both the trial and permanent implantation procedures using CPT 63650 in the hospital OPD will only be required to submit a PAR for the trial procedure. However, if the permanent implant occurs after the 120-day expiration date of the trial UTN, a new PAR will need to be submitted for the permanent implant.
2Q. If the trial implant is being rendered in an Ambulatory Surgical Center (ASC) or provider office, is a PAR required?
2A: No, PAR is only for trials rendered in the hospital OPD setting.
3Q. If the trial is rendered in a setting other than hospital OPD (ASC or provider office), is a PAR needed for the permanent implant?
3A: When the trial is rendered in a setting other than hospital OPD, providers will need to request PA for CPT 63650 as part of the permanent implantation procedure in the hospital OPD.
4Q: What is considered documentation of appropriate psychological evaluation?
Questions regarding topics not currently defined in CMS or First Coast published resources related to the PA program for certain hospital OPD services can be sent to
OPDPA@cms.hhs.gov.
If you have questions regarding Medicare processes, please contact the prior authorization customer service line at 855-340-5975.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
