NEUROMODULATION
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MEDICARE PRIOR AUTHORIZATION FOR HOSPITAL OUTPATIENT PROCEDURES

Beginning July 1, 2021, Medicare will require a prior authorization for beneficiaries undergoing a SCS or DRG trial or percutaneous permanent procedure in the hospital outpatient setting.

Office based or Ambulatory Surgical Centers (ASC) procedures are not affected by this Center for Medicare & Medicaid Services (CMS) mandate.



 

CPTCODE Description

63650

Percutaneous implantation of neurostimulator electrode array, epidural.

 

 

Medicare coverage policies, medical necessity and documentation are likely to remain unchanged.  Providers should check with their respective MAC to validate any need for additional documentation or unique procedural requirements.

CMS has made the following two documents available regarding the Prior Authorization Process:

PRIOR AUTHORIZATION WORKFLOW

The process of submitting a prior-authorization with Medicare is like the prior-authorization process for commercial payers. Medicare published prior authorization flow chart:

 

Prior Authorization Flowchart

https://www.cms.gov/files/document/opd-open-door-forum-slides-05-28-2020.pdf

Prior Authorization Process for certain Hospital Outpatient Departments services flow chart

 

MEDICARE ADMINISTRATIVE CONTRACTORS

A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims for Medicare Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims.

 

CGS cgsmedicare.com

  • J15 (Kentucky, Ohio)

First Coast fcso.com

  • JN (Florida, Puerto Rico and U.S. Virgin Islands)

NGS ngsmedicare.com

  • JK (Connecticut, New York, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont)
  • J6 (Illinois, Wisconsin, Minnesota)

Noridian med.noridianmedicare.com

  • JE (American Samoa, California, Guam, Hawaii, Nevada, North Marina Islands)
  • JF (Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming)

Novitas novitas-solutions.com

  • JL (Delaware, New Jersey, Pennsylvania, Maryland and the District of Columbia)
  • JH (Arkansas, Colorado, Louisiana, Mississippi, New MExico, Oklahoma and Texas Indian Health Service (HIS) and Veterans Affairs (VA))

Palmetto palmettogba.com

  • JJ (Alabama, Georgia, Tennessee)
  • JM (North Carolina, South Carolina, Virginia and West Virginia)

WPS wpsgha.com

  • J5 (Iowa, Kansas, Missouri, Nebraska)
  • J8 (Indiana, Michigan)

Indicates a third party trademark, which is property of its respective owner.


HE&R Disclaimer: 

This document and the information contained herein is for general information purposes only and is not intended, and does not constitute, legal, reimbursement, business, clinical, or other advice. Furthermore, it is not intended to and does not constitute a representation or guarantee of reimbursement, payment, or charge, or that reimbursement or other payment will be received. It is not intended to increase or maximize payment by any payer. Similarly, nothing in this document should be viewed as instructions for selecting any particular code, and Abbott does not advocate or warrant the appropriateness of the use of any particular code. The ultimate responsibility for coding and obtaining payment/reimbursement remains with the customer. This includes the responsibility for accuracy and veracity of all coding and claims submitted to third-party payers. In addition, the customer should note that laws, regulations, and coverage policies are complex and are updated frequently, and, therefore, the customer should check with its local carriers or intermediaries often and should consult with legal counsel or a financial, coding, or reimbursement specialist for any questions related to coding, billing, reimbursement or any related issues. This material reproduces information for reference purposes only. It is not provided or authorized for marketing use.

 

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