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Does reading the November 12, 2019 released calendar year 2020 Federal Register OPPS final rule somehow not make it to your list of “things to do”? If not, join the masses but you might have missed key information that will put your organization at a disadvantage or loss of revenue.

Buried in the plethora of changes for 2020 is one of which you will need to ensure your front line staff is aware of for Hospital Outpatient Departments under OPPS conditions for payment. As part of the initiative to protect Medicare funding, utilization of services and procedures furnished in hospital outpatient departments is constantly monitored by CMS (Centers for Medicare & Medicaid). Under this umbrella of services monitored resides certain procedures that potentially could be cosmetic or related to inherently cosmetic procedures; not performed necessarily for therapeutic reasons.  

Moving into July 1, 2020, the below five categories will require prior authorization as a condition for Medicare payment:

  • Blepharoplasty
  • Botulinum toxin injections
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation

The Federal Register states that, “We believe a prior authorization process for certain OPD services would ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Funds from improper payments, and at the same time keeping the medical necessity  documentation requirements unchanged for providers.”

What hospitals need to know now…

  • CMS will be expecting authorization prior to any services being furnished to the patient for the five procedures listed, for payment under OPPS. Without a prior authorization obtain, the procedure will be denied
  • CMS is expecting documentation to separately justify services as Medically Necessary for Conditions of Payment
  • This does not take place of LCD/NCD, prepayment/post payment reviews
  • This is for Medicare FFS, not Medicare Advantage and only pertains to hospitals that are receiving payment under OPPS
  • Implementation Schedule starts July 1, 2020
  • Start process related front end planning and education now to pertinent staff



Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Revisions of Organ Procurement Organizations Conditions of Coverage; Prior Authorization Process and Requirements for Certain Covered Outpatient Department Services; etc., 84 Fed Reg. 61142 (November 12, 2019) (to be codified at 42 CFR Parts 405, 410, 412, 414, 416, 419, and 486).

Healthcare Coding & Consulting Services

(a.k.a. HCCS)

This blog is an extension of our uncompromising values and dedication to our clients, staff, and the HIM industry as a whole.


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