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Prior authorization (PA) for hospital outpatient department (OPD) services: tips and reminders

First Coast has been processing prior authorization requests (PARs) since the implementation of the program and has found errors and omissions in these requests. These errors and omissions can result in delays or dismissals of the PAR. The following are tips and reminders that will assist providers in avoiding a delay or dismissal of a PAR.

PARs are required for certain OPD services billed on a type of bill 13X provided at a hospital OPD that are on the CMS list of procedures requiring PA. This means if the physician's place of service (POS) will be POS 19 or 22, a PAR will be required for the hospital OPD. A PAR is not required for ambulatory surgical centers (ASCs) or services performed in the physician's office (POS 11).

To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services. For more information on coverage and documentation requirements, refer to the general documentation requirements and medical documentation checklists.

PAR form

PARs have been dismissed as non-affirmed for incomplete or invalid information on the PAR coversheet. To prevent dismissals or processing delays of the PAR, First Coast encourages providers to use our PAR coversheet. To assist in avoiding common errors, instructions for completing the PAR are available.

  • To be valid, all fields on the PAR coversheet must be completed:
    • Include the facility and provider CMS Certification Numbers (CCNs) and NPIs in the proper fields
    • Include the correct MBI
    • Include only applicable CPT or HCPCS codes from the CMS list of procedures requiring PA
    • Do not include procedures codes for services that do not require PA
    • Addresses are required
    • Ensure the PAR is legible
  • Coversheet should be submitted along with appropriate documentation
  • Use the correct PAR coversheet:
    • Only use the expedited coversheet for life threatening situations
    • Ensure the PAR is being sent to the correct MAC
  • PAR resubmission must include:
    • The initial PAR coversheet
    • All documentation from the original submission
    • Any additional information/documentation
    • Unique tracking number (UTN) associated with the previous submission

PARs including photos

PARs have been dismissed due to photos being submitted to support the PAR as illegible or missing.

  • First Coast highly recommends using the SPOT portal for submitting photos. SPOT will provide the best quality and clarity for photos since they can be submitted in color
  • Submission of photos via fax or mail is not ideal due to the lack of clarity
    • Faxed photos are only black and white - do not have sufficient detail required to support the PAR 

Service specific issues identified

The following service specific issues have been identified on submitted PARs: 

Blepharoplasty, blepharoptosis repair, and brow ptosis repair

  • Records have been submitted with illegible writing. The documentation needs to be legible.
  • Visual field testing submitted without a full dictation of what was determined from the visual fields. An interpretation in writing of what the tests show to support medical necessity is needed.
  • Photos submitted were illegible or not included in the PAR. Follow the guidance above when including photos.

Botulinum toxin injections

  • PA is only required when one of the required botulinum toxin codes (J0585, J0586, J0587, or J0588) is used in conjunction with the one of the required CPT injection codes 64612 or 64615. To avoid a dismissal or delay in the PAR ensure the following is reported:
    • Providers must indicate the number of units of each code being requested separately (do not combine units).
    • Each J-code must correlate with the amounts specified by the CPT code.
    • The amount of the medication and injection must be specified in the documentation.

Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services 

  • Documentation submitted does not support the medical necessity specifically related to services performed 24 months after bariatric surgery and stable weight for 6 months within (5-10 pounds).
  • Photos submitted were illegible or not included in the PAR. Follow the guidance above when including photos.

Rhinoplasty and related services

  • If the beneficiary is having sinus surgery and a deviated septum repair is requested to get to the sinus cavity, this need to be specified in the documentation.
  • Photos submitted were illegible or not included in the PAR. Follow the guidance above when including photos.

Vein ablation and related services

Documentation must indicate prior treatment of three-month trial of conservative therapy which must include graduated compression stockings (12-18 mm Hg) with a minimum weight reduction to body mass index (BMI) less than 35, therapeutic leg elevation, and an exercise program of calf muscle pumping activity with compression of the involved veins. 

  • If BMI is not less than 35, there must be a reason explaining this (e.g., the beneficiary is bedbound).
  • Photos submitted were illegible or not included in the PAR. Follow the guidance above when including photos.

Spinal cord stimulator

  • Requesting the appropriate units of 63650 (for example: 2 units for two leads).
  • Psychological evaluation must be performed by a mental health professional and signed with the appropriate credentials.
  • Documentation must support this is a late if not last resort option for pain management.

Cervical fusion

  • Documentation of conservative therapy if applicable.
  • Request the appropriate CPT code and units for (22551, 22552) on the fax sheet if planning on performing a multi-level fusion to avoid resubmitting another request.