NASS Insider

May 11, 2021

New Medicare Prior Authorization Requirements for Two Spine Procedures Provided in Hospital Outpatient Departments

Effective July 1, 2021 the Centers for Medicare and Medicaid Services (CMS) has added two new services to the hospital outpatient department (OPD) Prior Authorization program. These services are:
  • Cervical Fusion with Disc Removal; CPT codes 22551 and 22552; and
  • Implanted Spinal Neurostimulators; CPT codes 63685, 63688
For dates of service beginning on or after July 1, 2021, prior authorization of these services will be required as a condition of payment. Medicare cites this strategy aims to ensure that beneficiaries receive only medically necessary care. Hospitals must submit a prior authorization request and receive a provisional affirmation decision as a condition of payment. Physicians and other third parties may submit the request on behalf of the hospital OPD, but hospital OPDs are responsible for ensuring that this condition of payment is met. All associated/related claims, including the physician’s, for these services submitted without a provisional affirmation decision will be denied.

The Medicare Administrative Contractors (MACs) are developing educational resources to assist physicians and hospitals with compliance. NASS encourages members to familiarize themselves with their MAC’s local coverage determination (LCD) and to utilize the available educational materials Following are links to each MAC’s prior authorization portal as well as currently available training specific to the new requirements. Please note that most MACs are in the process of adding information on the new service categories to their websites. Additionally, the MACs typically record webinars and post on their websites for viewing after the live date.

Webinar: June 23; 11:00 am -12:00 pm ET

First Coast
Webinar: May 26; 10:00-11:30 am ET

Webinar: May 12; 10:00-11:15 am ET

Webinar: June 16; 1:00-2:30 pm PT
Webinar: June 24; 3:30-5:00 pm PT

Webinar: May 27; 9:00-10:30 am CT

Palmetto GBA


Questions or comments regarding prior authorization can be directed to Allison Waxler, Director of Regulatory Affairs at NASS.