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Hospitals must keep abreast of the changes and nuances as CMS adds new procedures for prior authorizations. 

We are approaching the second year of the Centers for Medicare & Medicaid Services (CMS) Prior Authorization Program, coming up on July 1. With that anniversary comes the addition of new procedures to the list, as CMS expands the scope from the realm of cosmetic-like procedures into spinal surgery. But in early May, CMS modified the new procedure list, adding some nuances that are important to understand.

First, though, a reminder that this program only applies to procedures on the prior authorization list, if they are performed in hospital outpatient departments. CMS is aware that many of these procedures are also performed in physician offices and ambulatory surgery centers (ASCs), but the program rules do not allow them to require prior authorization in those settings. It is also worth noting that hospitals that have participated in the program and have been audited with at least a 90-percent approval rate will be allowed to proceed without obtaining prior authorization, including not being required to obtain prior authorization for the procedures that will be added July 1. Although they will be exempted, they will be subject to periodic audits to ensure that medical necessity is being met and properly documented.

The addition of prior authorization for cervical spine fusion, HCPCS 22551 and 22552, remains intact. CMS has not established a National Coverage Determination (NCD), and as of this date, no Medicare Administrative Contractor (MAC) has established a Local Coverage Determination (LCD). CMS has added to its operational guide a list of the required documentation elements that must be provided, including documentation of pain, limitations on the activities of daily living, conservative care provided, and so on. However, there is no Medicare-published standard to determine when surgery will be considered medically necessary.

The second group of codes added to the prior authorization list cover procedures for implantation of a spinal neurostimulator. Understanding the changes CMS made requires an understanding of the procedure. Unlike other implanted devices, such as a defibrillator or a pacemaker, patients undergo a trial with a neurostimulator prior to having the permanent device implanted. For this trial period, spinal neurostimulator electrodes are placed through the skin into the spine using X-ray guidance. The external end of the electrodes are hooked up to a portable stimulator. The placement of these test electrodes is coded with HCPCS code 63650. The patient then undergoes a trial period to determine if their pain is reduced. The temporary electrodes are removed, and the patient undergoes a much more complex open procedure, wherein permanent electrodes are implanted. The stimulator is then placed permanently under the skin. This procedure is coded with HCPCS code 63650 for the placement of the permanent electrodes and 63685 or 63688 for placement of the stimulator device.

When first announced, CMS was to require prior authorization for placement of the temporary electrode procedure, and a second prior authorization for the placement of the permanent device. But on May 13, CMS changed course, and now will only require prior authorization for the trial procedure. If only it were truly that easy. They added a note indicating that if the trial placement did not get a prior authorization, the permanent implantation must get one. And here is where it can get complex.

If the patient has the trial procedure and permanent placement done at the same hospital outpatient department, then everything should work fine. The hospital will have obtained the original authorization and will have the Unique Tracking Number (UTN) to place on both claims. But if that trial electrode placement was performed at another hospital as an outpatient service, the hospital will need to track down the original UTN to place on their claim. And if the trial placement was performed in an ASC or physician’s office, they will need to ensure that they obtain the prior authorization before the permanent implantation.

CMS’s experiment with prior authorization started in the midst of the COVID-19 pandemic, when surgeries of all types were postponed. As hospitals return to normal operations, it will be important to ensure that the rules for prior authorization are followed, and that hospitals keep abreast of the changes and nuances as CMS adds new procedures.  

Programming Note: Listen to Dr. Ronald Hirsch conduct his Monday rounds during Monitor Mondays, 10 a.m., and sponsored by R1 RCM.

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