Revised July 2022

Effective July 1, 2020 the Centers for Medicare & Medicare Services (CMS) began requiring prior authorization (PA) for hospital outpatient departments (HOPD) when any of the following eyelid surgeries or Botox injections are performed. This ruling does not impact ambulatory surgery centers (ASCs).

CMS has seen an increase in surgeries performed in HOPDs that qualify as either functional or cosmetic. Prior authorization should help avoid incorrect cosmetic payments and assure patients’ insurance benefits for functional procedures are covered.

In January 2022, CMS revised its guidance documents, removing 67911 from the PA requirement list and allowing physician providers to obtain authorizations directly on behalf of the hospital facilities and receive direct communications from carriers. 

CMS Removes Lid Surgery Code From Hospital Outpatient Prior Authorization List

Payment Denial

If no authorization is on file, the claim for the HOPD, surgeon and anesthesiologist will be denied. 

What CPT codes require prior authorization?

CMS Utilization Data

Facility vs Physician Responsibility

As of January 2022, either the physician office or the facility may request prior authorization. This is critical as the physicians have the material necessary to document medical necessity, as well as intended procedures and codes.

Physician

• Assess the patient for medical necessity.
• Documentation should support medical necessity and meet CMS and Medicare administrative contractor (MAC) policy requirements.
• Document the possibility (if any) of a procedure change intraoperatively.
• Schedule a tentative date with HOPD.
• If facility is requesting prior authorization:
  • Provide HOPD all supporting documentation.
    • Include all CPT and ICD-10 codes to be submitted.
  • Provide any additional documentation to HOPD that is requested.
• If physician office is requesting PA:
  • Submit prior authorization request to the MAC.
    • Resubmit if nonaffirmed decision.
  • Schedule the procedure if affirmed.

Facility

• Review documentation received to ensure it meets MAC requirements
• Request any additional necessary from the provider, prior to submission
• Submit PA request to MAC
• Resubmit if non‐affirmed decision
• Schedule procedure if affirmed
• Procedure is performed in facility
• Bill to Medicare using UTN and following all billing criteria

Prior Authorization Process

• Requests can be made by the HOPD or physician offices on behalf of the hospital facilities.
• This only applies for HOPD that use type of bill 13X — this does not apply for critical access hospitals as they use a different type of billing.
• MACs will respond with a prior authorization decision within 10 business days in the same format as the request was received.
• If a request is expedited, determination will be provided within two business days.
  • Documentation should support that a delay in response could severely impact life, health or limb.
• The determination is also sent to the patient.
• Upon receipt of the determination, claims submitted must include the unique 14-digit tracking number (UTN) assigned to request, or it will be denied.
• Prior authorization request should include:
  • Required information from the checklist
  • Supporting documentation that meets MAC policies
• Even though each prior authorization is valid for 120 days, each one is only good for one date of service. For example, if a provider performs Botox injections every 90 days, two prior authorizations must be obtained since they are for two dates of service.
• Although audits of records may still happen in certain situations, those who receive a provisional affirmation will likely not be included in reviews.
• Exemptions from prior authorization may be determined if compliance with requirements is consistent. To qualify, a minimum of 10 requests must be received and at least 90% must attain provisional affirmation upon semi-annual review. Notice is provided at least 60 days prior to the effective date. Achieving this percentage of provisional affirmations demonstrates the providers understanding of the requirements for submitting accurate claims.
• Advance Beneficiary Notice policies are unchanged and should still be followed.

Prior Authorization Determination

Eye Lid Surgery Prior Authorization Requirement Checklist

The following items are required to process prior authorization for eyelid surgery. Cover sheet request form is provided by each MAC

• Beneficiary’s name
• Medicare Beneficiary Identifier (MBI)
• Date of birth
• Facility information, including
  • Name
  • Address
  • NPI
  • PTAN/CCN
• Physician information, including
  • Name
  • Address
  • NPI
  • PTAN
• Requester’s information, including
  • Name
  • Telephone number
  • Address
• Anticipated date of service
• CPT surgical codes
• ICD-10 diagnosis codes appropriate for procedure, including laterality when appropriate
• Type of bill — 13X for outpatient hospital [PDF]
• Units of service
• Type of request
  • Indication whether this is an initial or resubmission review
  • Indication if review is to be expedited and reason 

Surgeon’s Preoperative Documentation Requirements

For the surgeon, documentation requirements for eye lid surgeries may vary even amongst Medicare payers.

Visit aao.org/lcds for your MACs preoperative documentation requirements.

Botulinum Toxin Injection Prior Authorization Requirement Checklist

The following items are required in order to process prior authorization and receive response. Cover sheet request form provided by each Medicare administrative contractor.

• Beneficiary’s name
• Medicare Beneficiary Identifier (MBI)
• Date of birth
• Facility information, including
  • Name
  • Address
  • NPI
  • PTAN/CCN
• Physician information, including
  • Name
  • Address
  • NPI
  • PTAN
• Requesters information, including
  • Name
  • Telephone number
  • Address
• Anticipated date of service
• CPT/HCPCS surgical/drug codes
• ICD-10 codes appropriate for the procedure, including laterality
• Type of bill
• Units of service
• Type of request
  • Indication whether this is an initial or resubmission review
  • Indication if review is to be expedited and reason
• Medical necessity documentation supporting anticipated procedure
  • Follow guidelines put forth by LCD policies and articles, if in place.

Surgeon’s Preoperative Documentation Requirements

For the surgeon, documentation requirements for eye lid surgeries may vary even amongst Medicare payers.

Visit aao.org/lcds for your MACs preoperative documentation requirements which may include but not be limited to the following:

• Support for the medical necessity of the botulinum toxin (type A or type B) injection
• A covered diagnosis
• Dosage and frequency of planned injections
• Documentation to support for the medical necessity of electromyography procedures performed in conjunction with botulinum toxin type A Injections to determine the proper injection site(s) (when applicable)
• Support of the clinical effectiveness of two consecutive injections (for continuous treatment)
• Specific site(s) injected
• For support of management of a chronic migraine diagnosis, the Medical Record must include a history of migraine and experiencing frequent headaches on most days of the month
• A documented statement that traditional methods of treatments such as medication, physical therapy and other appropriate methods have been tried and proven unsuccessful (when applicable)

Botox for Treatment of Blepharospasm, Hemifacial Spasm Fact Sheet (PDF)

Botox A for Treatment of Migraine (PDF)

Botulinum Toxin Injections for Correction of Strabismus (PDF)

Submit questions to coding@aao.org.

For more information, order the Academy's Learn to Code Oculofacial downloadable module (soon to be called Coding Assistant: Oculofacial)