What Radiology Practices Need to Know About Medicare’s Prior-Authorization Requirements
Beginning July 1,2020 Medicare required prior authorization for five procedure classes: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation. As a reminder, prior authorization was announced through the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS-1717-FC).
“The rule states if prior authorization is not obtained before the service is provided, all related claims, including anesthesiology services, physician services, and/or facility services, will be denied.”
For radiology practices, vein ablation is the procedure that could impact your practice negatively. With this new change, there are three steps your radiology practice needs to take to ensure payment for these procedures. Let’s take a look at what you need to know and do.
Know the codes impacted.
The first step is to know which codes are affected. You will need prior approval from Medicare for Code (v) Vein Ablation and related services, including:
| 36473 | Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
| 36474 | Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
| 36475 | Destruction of insufficient vein of arm or leg, accessed through the skin |
| 36476 | Radiofrequency destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
| 36478 | Laser destruction of incompetent vein of arm or leg using imaging guidance, accessed through the skin |
| 36479 | Laser destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
| 36482 | Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance |
| 36483 | Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance |
Ensure the documentation supports medical necessity.
To ensure prior approval, the documentation in the patient’s records must support medical necessity. This means that if the patient is a referral from another provider, you may need to request the patient’s records to ensure there is adequate documentation to support medical necessity. Otherwise, approval may not be granted, and reimbursement may be affected.
Prepare the patient.
As in all prior approval situations, there may be a waiting period before performing the procedure. It is important to communicate this to the patient to properly set expectations and ensure they understand the process and ramifications if the procedure does not gain approval. As these are the first procedures where Medicare requires prior approval, we will have to wait and see how long the approval process takes.
With these steps in place, your radiology practice will be prepared to comply with this new Medicare requirement and avoid reimbursement risks.
Watch the CMS prior-authorization website for additional information https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services.
By Donna Richmond, BA, RCC, CIRCC, CPC
