Prior Authorization for Certain Hospital Outpatient Department (OPD) Services MAC Provider Education and Coverage

on Tuesday, 19 May 2020. All News Items | Case Management | Documentation | Coding

Last week’s Wednesday@One included an article providing details about the CMS Prior Authorization Program for certain hospital outpatient department (ODP) services. As a reminder this program will begin for services provided on or after July 1, 2020. We have continued to follow Medicare Administrative Contractor (MAC) websites for news about the program. This article provides details about which MACs have scheduled provider education. Also included in this article, are tables posted on two different MACs websites that provide links to applicable Local Coverage Determinations (LCDs) and Articles.

 

J15 MAC: CGS Administrators, LLC (CGS)
Jurisdiction Area: Kentucky, Ohio

CGS is providing a webinar to introduce the new prior authorization program for certain hospital outpatient services on Thursday May 21, 2020 at 11:00 a.m. Eastern Time. You can go to the CGS Part A Calendar of Events to register for this webinar.

CGS has also created an OPD Prior Authorization webpage in the Medical Review section of their website. Currently you will find a list of applicable HCPCS codes. Also, Process and Results are “coming soon!” to this webpage.

 

JN MAC: First Coast Service Options, Inc.
Jurisdiction Area: Florida, Puerto Rico, U.S. Virgin Islands

On May 4th First Coast reminded providers that the CMS is implementing a prior authorization program for the following hospital outpatient department services for dates of service on or after July 1, 2020:

  • 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, and
  • Vein ablation and related services.

First Coast will be hosting two webcasts in which they will review the guidelines for submitting a Prior Authorization Request (PAR) and the potential results and options available. Specialists will be present to answer questions relating to the process. The dates for the webcasts are Thursday, May 28th and Thursday, June 11th. To register for a webcast you can go to the First Coast events calendar under their Education Section of their website (https://medicare.fcso.com/index.asp). To learn more the Prior Authorization Program you can look under the Medical Review section of the website.

 

First Coast JN: Documentation Guidance

First Coast has posted the following table on their website to provide more information on coverage and documentation requirements.

Dates of ServiceLCD/LCD Article/NCDType of Service
For services performed on or after January 1, 2019 Local Coverage Determination (LCD): Upper Eyelid and Brow Surgical Procedure (L34028) Blepharoplasty
For services performed on or after October 31, 2019 Local Coverage Article: Billing and Coding: Surgery: Blepharoplasty (A57618) Blepharoplasty
For services performed on or after January 8, 2019 Local Coverage Determination (LCD): Botulinim Toxins (L33274) Botulinum toxins
For services performed on or after January 1, 2020 Local Coverage Article: Billing and Coding: Cosmetic and Reconstructive Surgery (A56587) Panniculectomy and rhinoplasty
For services performed on or after November 27, 2019 Local Coverage Determination (LCD): Treatment of varicose veins of the lower extremity (L33762) Vein ablation
For services performed on or after January 1, 2020 Local Coverage Article: Billing and Coding: Non-Invasive Peripheral Venous Studies (A52993) Vein ablation

 

JK and J6 MAC: National Government Services, Inc. (NGS)
JK Jurisdiction Area: Connecticut, New York, Main, Massachusetts, New Hampshire, Rhode Island, Vermont
J6 Jurisdiction Area: Illinois, Minnesota, Wisconsin

As of Monday May 18th, MMP was unable to find any information about this program or planned provider education on the NGS website.

 

JE and JF MAC: Noridian Healthcare Solutions, LLC (Noridian)
JE Jurisdiction Area: California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands
JF Jurisdiction Area: Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming

Noridian will be hosting webinars on the following dates:

  • May 28, 2020,
  • June 4, 2020,
  • June 10, 2020,
  • June 18, 2020, and
  • June 24, 2020.

This Provider Outreach and Education (POE) webinar will include the following:

  • Overview,
  • Authorization Process,
  • Submitting Prior Authorization Request,
  • Services Requiring Prior Authorization,
  • Advanced Beneficiary Notice of Noncoverage (ABN)
  • Cosmetics, and
  • Resources

Link to Webinar Announcement on JE website: https://med.noridianmedicare.com/web/jea/article-detail/-/view/10521/prior-authorization-for-certain-hospital-outpatient-department-opd-services-webinars

Link to Webinar Announcement on JF website: https://med.noridianmedicare.com/web/jfa/article-detail/-/view/10529/prior-authorization-for-certain-hospital-outpatient-department-opd-services-webinars

JH and JL MACs: Novitas Solutions, Inc. (Novitas)
JH Jurisdiction Area: Arkansas, Colorado, New Mexico, Oklahoma, Texas, Louisiana, Mississippi 
JL Jurisdiction Area: Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania

Novitas will be hosting a webinar on Thursday May 28, 2020. This webinar will review the details and submission guidelines for the Prior Authorization (PA) program for certain hospital outpatient department (OPD) services being implemented by the Centers for Medicare & Medicaid Services (CMS) effective June 17, 2020, for dates of service on or after July 1, 2020, nationwide. 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. You can register for this webinar on the Novitas Medicare Part A Educational Event Calendar webpage at: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00008010

 

Novitas JH and JL: Documentation Guidance:

Similar to First Coast, Novitas has posted the following table on their website providing more information on coverage and documentation requirements.

Dates of ServiceLCD/LCD Article/NCDType of Service
For services performed on or after 10/31/2019 Local Coverage Determination (LCD):
Surgery: Blepharoplasty (L35004)
Blepharoplasty
For services performed on or after 10/31/2019 Local Coverage Article:
Billing and Coding: Surgery: Blepharoplasty (A57618)
Blepharoplasty
For services performed on or after 10/31/2019 Local Coverage Determination (LCD):
Nerve Conduction Studies and Electromyography (L35081)
Botulinum toxin injections
For services performed on or after 11/07/2019 Local Coverage Determination (LCD):
Cosmetic and Reconstructive Surgery (L35090)
Panniculectomy and Rhinoplasty
For services performed on or after 1/1/2020 Local Coverage Article:
Billing and Coding: Cosmetic and Reconstructive Surgery (A56587)
Panniculectomy and Rhinoplasty
For services performed on or after 11/14/2019 Local Coverage Determination (LCD):
Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities (L34924)
Vein ablation
For services performed on or after 10/17/2019 Local Coverage Determination (LCD):
Non-Invasive Peripheral Venous Studies (L35451)
Vein ablation
For services performed on or after 1/1/2020 Local Coverage Article: Billing and Coding: Non-Invasive Peripheral Venous Studies (A52993) Vein ablation

 

JJ and JM MAC: Palmetto GBA, LLC (Palmetto)
JJ Jurisdiction Area: Alabama, Georgia, And Tennessee
JM Jurisdiction Area: North Carolina, South Carolina, Virginia, West Virginia

On May 13th Palmetto release an article letting providers know they will be providing a two-part webcast on May 26, 2020 regarding the Outpatient Department (OPD) Prior Authorization (PA) program. The first session will be an overview of the program and begins at 10 a.m. ET. The second session will begin at 1 p.m. ET and will discuss “Medical Necessity.” These webcasts are available for Medicare Part A and Part B providers. Links to register for both sessions are included in the Article.  

The next day on May 14th, Palmetto included in their Daily Newsletter the following article specific to the procedures in this program:

All of the articles include details about documentation requirements and a procedure specific Documentation Checklist.

J5 and J8 MAC: Wisconsin Physician Service Government Health Administrators (WPS)
J5 Jurisdiction Area: Iowa, Kansas, Missouri, Nebraska
J8 Jurisdiction Area: Indiana, Michigan

WPS has scheduled a teleconference that will cover the new prior authorization process, the services specific to this process, and the responsibilities of both the physician and the facility. This training is intended for J5 and J8 Part A/B providers billing on a UB-04/CMS-1500 or electronic equivalent. There will be two different sessions both held on June 10, 2020. The first teleconference will be from 10:00 AM – 11:30 AM CT and the second session will be from 1:00 PM – 2:30 PM CT. You can sign up for these sessions on the WPS Learning Center at: http://wpsghalearningcenter.com/login.

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc.  Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. 

In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Risk Assessment (CRA) Tool. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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