Prior authorization program for certain hospital outpatient department services
The Centers for Medicare & Medicaid Services (CMS) is implementing a prior authorization program for certain hospital outpatient department (OPD) services for dates of service (DOS) on or after July 1, 2020. CMS believes prior authorization for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Fund from improper payments and keeping the medical necessity documentation requirements unchanged for providers.
As a condition of payment for DOS on or after July 1, 2020, a Prior Authorization Request (PAR) is required for the following hospital OPD services:
• Blepharoplasty, eyelid surgery, brow lift, and related services
• Botulinum toxin injections
• Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services
• Rhinoplasty and related services
• Vein ablation and related services
CMS provides a list of the specific Healthcare Common Procedure Coding System (HCPCS) codes that are included in the OPD Prior Authorization program.
SPOT users can upload and submit their OPD PARs through the secure documentation functionality on SPOT. Not a SPOT user? Learn more and register today.
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