Medicare requires prior authorization for venous ablation

Radiologists who perform venous ablation in a hospital outpatient department are now required to obtain prior authorization before performing such services on Medicare patients. This new requirement became effective for services performed on or after July 1, 2020, and physicians were notified by letters from the U.S. Centers for Medicare and Medicaid Services (CMS) late in June.

The prior authorization requirement was included in the 2020 Hospital Outpatient Prospective Payment System (HOPPS) final rule, and it encompasses the following procedures that might be performed by interventional radiologists:

Other nonradiology procedures that will require prior authorization include the following:

• Blepharoplasty, eyelid surgery, brow lift, and related services
• Botulinum toxin injection
• Panniculectomy, excision of excess skin and subcutaneous tissue, and related services (including lipectomy)
• Rhinoplasty and related services

The prior authorization program does not create new documentation requirements, according to the CMS letter; however, the request for prior authorization does require that documentation be submitted to the Medicare Administrative Contractor (MAC) to show that the service meets applicable Medicare coverage, coding, and payment rules. Each MAC will determine the specific method to be used for the practices in its coverage area to submit requests.

The documentation requirements for venous ablation include the following:

• Doppler ultrasound
• Documentation stating the presence or absence of DVT (deep vein thrombosis), aneurysm, and/or tortuosity (when applicable)
• Documented incompetence of the valves of the saphenous, perforator, or deep venous systems consistent with the patient's symptoms and findings (when applicable)
• Photographs if the clinical documentation received is inconclusive
• The patient's medical record must contain a history and physical examination supporting the diagnosis of symptomatic varicose veins (evaluation and complaints), and the failure of an adequate (at least three months) trial of conservative management (before the initial procedure).

The request for prior authorization must be made by the hospital outpatient department, or by a physician on behalf of the hospital, and approval must be obtained before the service is performed and before the claim is submitted. Physician services for the procedure that are payable under the Medicare Physician Fee Schedule (MPFS) are covered by the authorization issued to the hospital.

A determination will be made within 10 business days; however, an expedited two-day review may be requested when a delay could seriously jeopardize the patient's life, health, or ability to regain maximum function. Documentation supporting the need for the expedited review must be submitted with the request.

The decision will be valid for 120 days after it is issued. Note that the authorization will be valid for a single claim or date of service. Since venous ablation procedures are sometimes staged, a separate prior authorization request will be required for each procedure. Multiple procedures on the same date of service should be included in a single authorization request.

A positive response to the request is considered a "provisional affirmation" of coverage, which means that a claim for the service will meet Medicare's coverage, coding, and payment requirements. In the event a nonaffirmation decision is received, the provider has the opportunity to resubmit their request an unlimited number of times with any applicable additional relevant documentation. The MAC will provide a detailed reason for its nonaffirmation decision.

A claim for services requiring prior authorization that is submitted without a provisional affirmation will be denied. The denial will be an initial denial, and a redetermination request may be submitted to Medicare. Any and all services associated with the denied venous ablation procedure, such as anesthesiology, or physician or facility services, will also be denied because those services would be unnecessary if the venous ablation had not been performed.

Once the program becomes established, CMS will perform semiannual assessments of providers' compliance with Medicare coverage, coding, and payment requirements for these procedures. Providers with a compliance level of at least 90% will be granted an exemption from the prior authorization requirement beginning sometime in 2021. An exemption will take up to 90 days to become effective and it will remain in effect until CMS withdraws it, in which case they will give 60 days' notice.

This is the first time the traditional Medicare program has required prior authorization for physician services to its beneficiaries. The current rule applies only to procedures performed in a hospital outpatient setting, those with a Place of Service code 19 or 22, but not for procedures done in a physician office or imaging center.

The CMS web site contains a list of frequently asked questions as well as a detailed operational guide related to the new program. We will continue to monitor and report on developments in the Medicare program and with other payors that will affect your practice's ability to maximize it revenue.

Sandy Coffta is the vice president of client services at Healthcare Administrative Partners.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.