In a few short weeks, the prior authorization requirements promulgated in the 2023 Hospital Outpatient Prospective Payment (“OPPS”) Final Rule (CMS-1772-FC) will become effective. Specifically, facet joint interventions have been added to the list of hospital outpatient department (“HOPD”) services requiring prior authorization (“PA”). Under the PA process, providers must submit a PA request, along with the required documentation before the service is rendered and receive a provisional affirmation as a condition of payment.
Background
The Centers for Medicare and Medicaid Services (“CMS”) calculated the rate of HOPD claims submitted for payment to the Medicare program typically increase by one percent (0.6%) a year, whereas facet joint interventions have increased by forty-seven percent (47%) between 2012 and 2021, reflecting a four percent (4%) average annual increase. [1]
Adding to the increased volume of procedures, recent reports from the Office of Inspector General (“OIG”) cited improper payments and questionable medical necessity of facet joint interventions. Accordingly, effective July 1, 2023 facet joint interventions have been added to the HOPD PA list as a means to control unnecessary increases in volume of services, and to help reduce instances where Medicare makes payment for services later deemed as not medically necessary.
Is your facility prepared to manage this new requirement, or are you trying to determine if it even applies to your organization? We break down the “who, what, when, where and how” as well as the potential for risk of audit.
Who is required to comply with the facet joint procedure PA requirement?
Only HOPDs must submit a PA request to receive a written decision with provisional affirmation. That said, associated/related professional services will also be denied when there is a non-affirmation PA decision for the HOPD facet joint procedure.
What facet joint interventions fall under this requirement?
Diagnostic or therapeutic facet joint injections (CPT codes 66490-66495) as well as facet joint neurolytic destruction procedures (CPT codes 64633-64636) are included in the HOPD PA program. Of note, any applicable Local Coverage Determination (“LCD”) medical necessity and documentation requirements are also still in effect.
When should my facility request prior authorizations for facet joint interventions and when do exemptions apply?
Navigating timelines for PA requests, responses and patient scheduling can be a challenge. The PA requirement goes into effect for dates of service on or after July 1, 2023. As such, patient scheduling for these procedures from this point forward will need to account for turn-around times for submission and CMS response.
CMS will review the PA request and issue a provisional affirmation or non-affirmation within ten (10) business days of receipt. Providers may request an expedited review (within two (2) business days) when the patient’s life, health, or ability to regain maximum function is in jeopardy.
If your HOPD reaches a combined affirmation rate of ninety percent (90%) or greater for all eight (8) service categories on the PA list in the previous annual exemption cycle, your Medicare Administrative Contractor (“MAC”) will issue an exemption to the PA process. Once exempted, a provider will receive an annual Additional Documentation Request (“ADR”) for a ten-claim sample to determine ongoing exemption status.
Where is the PA requirement enforced?
The hospital outpatient department setting is defined as visits and/or services/procedures paid under Medicare OPPS and submitted with bill type 13x. Physician’s offices, Critical Access Hospitals (“CAHs”), and Ambulatory Surgery Centers (“ASCs”) are not required to submit PA requests.
How long is a provisional affirmation decision good for, and what do we do if a non-affirmation decision is received?
A provisional affirmation decision is only valid for one hundred twenty (120) days from the date of decision, after which a new PA request must be submitted. We caveat, this does not mean that subsequent facet joint procedures also within this time frame are approved. Each procedure requires a new PA request regardless of whether the next service falls within the one hundred twenty (120) day period.
Procedures with a non-affirmation decision can be resubmitted for PA request an unlimited number of times, assuming the claim has not yet been submitted for payment. Of note, resubmission should include new additional documentation for consideration. If a claim has been submitted with a non-affirmation decision and is denied, this initial determination can be appealed.
Retrospective Claim Review
The OIG issued a report on March 22, 2023, which was based on an audit of claims during August 1, 2021 through October 31, 2021, indicating Medicare improperly paid an estimated $30 million for spinal facet-joint interventions. The OIG therefore recommended the MAC’s develop training programs specific to the Medicare requirements for facet-joint interventions and develop solutions to prevent the incorrect billing.
Based on the findings of the OIG and our experience in the industry, conducting a proactive audit of facet joint interventions now will help inform facilitates of potential retrospective risks as well as denials under the new PA program. If the audit is not conducted prior to July 1, 2023, facilities should also be alert to the volume of denials, as that could be indicative of retrospective risk.
Still have questions or need help evaluating your workflows surrounding facet joint procedures?
SunStone Consulting offers comprehensive services geared to help hospitals and health systems evaluate and navigate the ever-changing regulatory environment. If you have any questions, please contact:
Vonda Moon, Senior Principal at vondamoon@sunstoneconsulting.com
Joli Fitzgibbons, Director at jolifitzgibbons@sunstoneconsulting.com
Danielle Wyld, Senior Manager at daniellewyld@sunstoneconsulting.com