Prepare Now: Prior Authorization for Facet Joint Intervention Begins July 1

The Centers for Medicare and Medicaid Services (CMS) has added a new service category — Current Procedural Terminology® (CPT®) codes 64490-64495 and 64633-64636 when performed in a hospital outpatient department (OPD) place of service 19 (off-campus outpatient hospital), or 22 (on-campus outpatient hospital) — to the OPD Prior Authorization program. The new service category, which begins July 1, is relevant to interventional radiologists as it will require prior authorization as a condition of payment for facet joint interventions. The category was included in the 2023 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS-1772-FC).

The ACR®, along with medical specialty societies comprising physicians who utilize and/or perform interventional spine procedures, submitted a letter to the CMS Administrator Chiquita Brooks-Lasure to strongly urge CMS not to apply the prior authorization requirement to facet joint interventions, as this requirement creates an improper and unnecessary burden on the healthcare delivery system.

The new service category is in addition to existing prior authorization services, which include blepharoplasty, botulinum toxin injection, rhinoplasty, panniculectomy, vein ablation, cervical fusion with disc removal and implanted spinal neurostimulators. The prior authorization request (PAR) must be submitted before the service is provided to the beneficiary and before the claim is submitted for processing. The PAR will not be accepted after the service has been completed. The request must include all documentation necessary to show that the service meets applicable Medicare coverage, coding and payment rules.

Introductory letters will be mailed within the next few weeks to providers currently billing for facet joint interventions in hospital OPDs. Providers should monitor communication from their respective Medicare Administrative Contractor. Send feedback regarding the new service category to CMS at OPDPA@cms.hhs.gov.

For more information, please see the Transmittal 11753 and Change Request 13016, Provider Education for Prior Authorization Process for Facet Joint Interventions in the Hospital Outpatient Department Setting.

If you have questions or would like more information about this prior authorization program and activities, contact Alicia Blakey, ACR® Principal Economic Policy Analyst.