July 1 – New Medicare Prior Authorization Requirement for Facet Procedures

June 8, 2023

Effective July 1, the Centers for Medicare and Medicaid Services (CMS) has expanded its Prior Authorization for Certain Hospital Outpatient Department (OPD) Services program to include facet joint procedures.  Specifically, CPT codes 64490-64495 and 64633-64636, will require prior authorization when performed in a hospital outpatient department.  This includes both place of service 19, off-campus outpatient hospital) and place of service 22 (on-campus outpatient hospital).   Prior authorization is not required for facet procedures provided in other places of service. 

Providers who typically bill facet procedures performed in hospital outpatient departments should have received a letter describing this new requirement in the spring.  When the program begins next month, prior authorization requests can be submitted through the Electronic Submission of Medical Documentation (esMD) platform.  The addition of facet procedures to the OPD Prior Authorization program was finalized in the 2023 Outpatient Prospective Payment System final rule.  AAPM&R voiced concerns about this policy change in our comment letter last September.  Reducing physician burden associated with prior authorization policies is a key advocacy priority for the Academy.  If you have any questions, please contact healthpolicy@aapmr.org.