New Prior Authorization Requirements for Blepharoplasty and Botox in HOPDs

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Effective July 1, 2020, there are new rules for hospital outpatient departments (HOPDs): Before clinicians perform eyelid surgery or inject Botox (botulinum toxin), the HOPD must 1) request a prior autho­rization and 2) receive a provisional affirmation decision.

Start early. To allow HOPDs to set up their July schedule, MACs are supposed to start accepting such requests on June 17. Electronic submission via the Electronic Submission of Medical Documentation System (esMD) will not be available until July 6. The American Academy of Ophthalmic Executives (AAOE) recommends that you begin coordination with your HOPD early to ensure that your authorization is successful.

Using an ASC? The new rules don’t impact ambulatory surgery centers.

Why the new requirement? The Centers for Medicare & Medicaid Services (CMS) has seen an increase in HOPD surgeries that, depending on the circumstances, can qualify as either functional or cosmetic. By making prior authorization compulsory, the agency hopes to avert incorrect payments when the purpose of the surgery is cosmetic and assure that patients are covered when the purpose is functional.

Prior Authorization in Action

The HOPD and your practice collab­orate in filling out the paperwork and supplying the documentation, and then the HOPD sends the request to its Medicare Administrative Contractor (MAC).

What should the request include? Include what’s listed on the prior autho­rization checklist, plus supporting documentation that meets the MAC’s requirements.

A turnaround of up to 10 days. MACs should make a decision and send their response within 10 business days. How the HOPD submits the request (e.g., by mail, fax, or online) is likely to determine how the MAC sends its response. (Note: With that being said, MACs can send a copy of the decision via fax if a valid fax number is provided, even if the submission was sent via mail.) The MAC also notifies the patient about its decision.

What about emergencies? If an HOPD asks for a request to be expedit­ed, the MAC will respond within two business days. However, the request must document how a delay could severely impact life, health, or limb.

No UTN, no payment! The UTN is the unique tracking number that a MAC assigns to a request for prior authoriza­tion; look for it in the MAC’s response. Next, when you submit your claim, make sure you include the UTN in the correct places (e.g., in positions 1-18 for electronic claims).

What about ABNs? Advance Beneficiary Notice (ABN) policies are unchanged and should still be followed.

What about audits? While audits of records may still happen, if you received a provisional affirmation for a service, the claim for that service is unlikely to be included in a review.

Eventually, some HOPDs may be exempt from prior authorization. CMS is authorized to allow exemptions from the process for providers who can demonstrate consistent compliance with Medicare’s requirements. What is consistent compliance? CMS materials state that an HOPD must submit at least 10 requests and at least 90% of those must get a provisional affirma­tion. The agency doesn’t expect to start approving any exemptions until 2021.

Eyelid Surgery

HOPDs must obtain prior authoriza­tion for the following CPT codes.

Blepharoplasty:

• 15820 lower eyelid
• 15821 lower eyelid; with extensive herniated fat pad
• 15822 upper eyelid
• 15823 upper eyelid; with excessive skin weighting down lid

Repair of brow ptosis:

• 67900 supraciliary, mid-forehead or coronal approach

Repair of blepharoptosis:

• 67901 frontalis muscle technique with suture or other material (e.g., banked fascia)
• 67902 frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
• 67903 (tarso) levator resection or advancement, internal approach
• 67904 (tarso) levator resection or advancement, external approach
• 67906 superior rectus technique with fascial sling (includes obtaining fascia)
• 67908 conjunctivo-tarso-Muller’s muscle-levator resection (e.g., Fasanella-Servat type or MMCR)

Correction:

• 67911 Correction of lid retraction

Before you submit your request, make sure you read the AAOE prior authorization checklist for eyelid surgery. 

Note: In addition to the information listed in the AAOE checklist, the MAC will also want documentation that supports the request. What documentation is required for eyelid surgery? This varies among Medicare payers. Visit aao.org/lcds to see if your MAC preoperative documentation requirements go beyond what is listed below. (Note: The prior authorization process makes no changes to medical necessity requirements.)

General documentation requirements for blepharoplasty, eyelid surgery, brow lift, and related services typically include the following:

• Documented excessive upper/ lower lid skin;
• Supporting pre-op photos;
• Signed clinical notes support a decrease in peripheral vision and/or upper field vision;
• Signed physician’s or non-physician practitioner recommendations;
• Documented subjective patient complaints which justify functional surgery (vision, ptosis, etc.);
• Visual field studies/exams (when applicable).

Botox Injection

HOPDs require prior authorization for the following CPT and HCPCS codes.

Chemodenervation of muscle(s):

• 64612 muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)
• 64615 muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (e.g., for chronic migraine)

HCPCS codes for the injected medication:

• J0585 onabotulinumtoxina, 1 unit
• J0586 abobotulinumtoxina
• J0587 rimabotulinumtoxinb, 100 units
• J0588 incobotulinumtoxina, 1 unit

Before you submit your request, make sure you read the AAOE prior authorization checklist and list of preoperative documentation requirements for Botox injections. 

Your MAC Can Make Three Provisional Decisions

When you submit a request for prior authorization, your MAC can respond with a provisional affirmation, a provisional non-affirmation, or a provisional partial affirmation.

A provisional affirmation decision is a preliminary finding that a future claim submitted to Medicare for the item or service would be likely to meet Medicare’s coverage, coding, and payment requirements.    

A provisional non-affirmation decision is a preliminary finding that the MAC thinks that a future claim submitted to Medicare would not meet Medicare’s coverage, coding, and payment requirements. The MAC is supposed to include its reasons for making such a decision.

A provisional partial affirmation decision means that one or more service(s) on the request received a provisional affirmation decision and one or more service(s) received a non-affirmation decision.