American Society of Plastic Surgeons
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  1. Health Policy

CMS Policy – Prior Authorization for Outpatient Procedures

The Centers for Medicare and Medicaid Services (CMS) established a nationwide prior authorization (PA) process for certain hospital outpatient department (OPD) services. The Agency believes PA will ensure that Medicare beneficiaries continue to receive medically necessary care – while protecting the Medicare Trust Fund from improper payments and, at the same time, keeping the medical necessity documentation requirements unchanged for providers.

The following hospital OPD services will require prior authorization when provided on or after July 1, 2020:

  1. Blepharoplasty
  2. Botulinum toxin injections
  3. Panniculectomy
  4. Rhinoplasty
  5. Vein ablation

A detailed list of the codes impacted can be found here.

CMS has developed a webpage dedicated to this program and posts updates as they become available. To see the most current developments, please click here.

Consider these next steps to ensure your office is prepared for the new PA processes:

  1. Verify practice management software and billing software eligibility requests are updated to recognize these CPT Codes requiring PA.
  2. Establish a protocol to consistently document data required for PA in the medical record.
  3. Identify and select the PA method that will be most efficient for your office.
    • e.g., Payer portal, electronic transaction, fax, telephone or secure email
  4. Identify best practice for follow-up to ensure PA is processed and/or denials addressed timely