• CMS Removes Lid Surgery Code From Hospital Outpatient Prior Authorization List


    The Centers for Medicare & Medicaid Services has acceded to Academy-led efforts to eliminate or at least reduce the unnecessary burden imposed by CMS’ prior authorization program for hospital outpatient department services, including removing CPT code 67911, a type of corrective lid surgery, from the list.

    The Academy and American Society of Ophthalmic Plastic and Reconstructive Surgery partnered in a yearlong effort to limit the hospital outpatient program and revise problematic definitions that caused confusion and denials.  

    Effective Friday, Jan. 7, CMS will take 67911 off the prior authorization requirement list of hospital outpatient procedures. We’re also pleased to report that CMS has accepted our organizations’ feedback and made other updates to guidance documents and to its hospital outpatient department program.

    It’s “a sweet victory, especially with lid retraction, but not an open ticket for (blepharoplasty)/ptosis … ” said Jeffrey P. Edelstein, MD, chair of the Academy’s health policy committee. Medicare Administrative contractors may still conduct targeted pre- and post-payment reviews if a provider shows evidence of potential fraud or gaming the system, he added. “In this environment, it would be insane to do eyelid procedures without photos to back up your billing decisions.”

    We last reported that at a meeting with the Academy, CMS officials expressed openness to reviewing services on the prior authorization list and removing services that would never be done for cosmetic purposes, as well as to update terminology and guidance documents that have complicated approvals.

    CMS notified the Academy that the agency had agreed to update terminology and other edits that the Academy and the society suggested. Coming after months of meetings, letters and congressional pressure, it’s a significant victory and an unusual step for CMS.

    Other key components of the revisions include:

    • CMS will continue to allow physician providers to obtain authorizations directly on behalf of the hospital facilities and receive direct communications from carriers, as we requested. This is critical as the physicians have the material necessary to document medical necessity, as well as intended procedures and codes.
    • CMS revised the exemption process by extending the exemption cycle and including an option to opt-out of the exemption process for providers (facilities) that wish to continue submitting prior authorization requests. The opt-out choice was something that our societies and others requested. It would eliminate the obligatory post-payment review that an exemption would entail. However, it will require coordination between physician offices and the hospital facility moving forward as the hospital must request it.
    • CMS revised the title of the blepharoplasty service category from “Blepharoplasty, Eyelid Surgery, Brow Lift and related services” to “Blepharoplasty, Blepharoptosis Repair and Brow Ptosis Repair.”
    • Several code descriptions (67900, 67903, and 67904) were edited to more accurately these services and their definitions.
    • CMS reworded the documentation requirements for blepharoplasty in the operational guide.

    The definitions for two codes, 64612 and 64615, need additional clarification, and we plan to follow up with CMS staff. You can review the announcements and updated guidance.

    Prior authorization requirements are among the top complaints the Academy has received in recent years, and we’ve heard you. Even though this was a positive step for oculofacial plastic specialists, we will continue to press for broader relief from these administrative burdens.