Radiology Coding Alert

Healthcare providers often need to receive prior authorization approval before performing certain procedures, such as magnetic resonance imaging (MRI) exams and other advanced imaging services. However, prior authorization is starting to receive reform with recent rulings and payer policy changes.

Learn how these changes will affect your radiology practice’s billing.

Prepare for Prior Authorization Changes

The American Medical Association (AMA) and medical specialty societies have pushed for prior authorization reforms for years, and both public and commercial payers have made changes recently.

Understand UHC Adjustments: On March 29, 2023, UnitedHealthCare announced they will be reducing the number of prior authorizations by nearly 20 percent starting on July 1, 2023. The prior authorization reduction goal is to simplify healthcare for providers and patients. U.S. Reps. Mike Kelly and Suzan DelBene, who sponsored the Improving Seniors’ Timely Access to Care Act, reacted positively to UnitedHealthCare’s announcement.

“It’s my hope that today’s announcement by UnitedHealth is the first of many announcements from commercial insurers about much-needed reforms to prior authorization,” Rep. Kelly said in a press release (https://kelly.house.gov/media/press-releases/kelly-applauds-unitedhealth-announcement-it-will-cut-prior-authorizations).

Congresswoman Delbene echoed Congressman Kelly’s sentiments and added that the change is long overdue. “The news that UnitedHealthcare and other private Medicare Advantage plans are finally reducing burdensome paperwork that is a regular barrier to seniors receiving the care they deserve is a step in the right direction. But seniors and their families shouldn’t be beholden to corporate goodwill. These changes should have been instituted long ago,” DelBene said (https://delbene.house.gov/news/documentsingle.aspx?DocumentID=3441).

On Sept. 14, 2022, U.S. lawmakers unanimously passed the Improving Seniors’ Timely Access to Care Act. This bill aimed to reform the prior authorization process by establishing an electronic prior authorization process and requiring real-time decisions to be issued by insurers.

Consider CMS Prior Authorization Changes: The Centers for Medicare & Medicaid Services (CMS) issued a final rule on April 5, 2023, that revised the Medicare Advantage (MA or Part C), Medicare Prescription Drug Benefit (Part D), Medicare Cost Plan, and Programs of All-Inclusive Care for the Elderly (PACE) regulations for 2024. Among the changes in the final rule are adjustments to prior authorization, which go into effect on June 5, 2023.

The final rule aims to simplify prior authorization requirements, add coordinated care plan requirements, and minimize care disruptions for Medicare Advantage beneficiaries.

1. Coordinated care plan confirmation: Under this ruling, CMS finalized that coordinated care plan prior authorization policies may only be used to validate if a service or item is medically necessary and to confirm the existence of medical diagnoses or other medical criteria.
2. Three-month transition: If a patient switches to a new Medicare Advantage plan, while undergoing active treatment for which they already received prior authorization approval, CMS finalized a 90-day transition period where the new plan cannot require prior authorization for ongoing treatments.
3. Annual reviews: CMS requires all Medicare Advantage plans to have a Utilization Management Committee to review their prior authorization policies yearly, making sure they align with Traditional Medicare’s coverage decisions and guidelines.
4. Prevent care disruption: Prior authorization request approval is valid for the approved course of treatment’s duration if the treatment is medically necessary, based on the patient’s medical history and the treating provider’s recommendation, to avoid disruptions in care.

In a response to the final rule, the AMA approves of the prior authorization adjustments. “[A]n initial read suggests that [CMS] has taken important steps toward right-sizing the prior authorization process imposed by Medicare Advantage plans on medical services and procedures,” wrote Jack Resneck Jr., MD, president of the AMA in a press release. “The AMA applauds CMS Administrator Brooks-LaSure for leading the effort to include provisions in this final rule that will ensure greater continuity of care, improve the clinical validity of coverage criteria, increase transparency of health plans’ prior authorization processes, and reduce care disruptions due to prior authorization requirements.”

Be Aware of Additions to the Prior Authorization Program

On February 22, 2023, the American College of Radiologists (ACR) alerted its members of key additions to the hospital outpatient department (OPD) Prior Authorization Program. Effective July 1, 2023, providers will need prior authorization approval before performing the following procedures:

• 64490-64495 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT) …)
• 64633-64636 (Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT) …)

These facet joint intervention code ranges pertain to interventional radiologists, as the providers will need prior authorization as a condition of payment for the procedures. While some payers are reducing their prior authorizations to simplify care, CMS is requiring prior authorization for each facet joint injection procedure.

On April 11, 2023, CMS released a frequently asked question (FAQ) document pertaining to the prior authorization process for certain hospital outpatient department (OPD) services. The agency stated that each prior authorization request process-unique tracking number (UTN) for facet joint injections is valid only for one claim. According to CMS, each facet joint intervention procedure will require a new prior authorization request “regardless of whether the next service falls within 120 days” (www.cms.gov/ files/document/opd-frequently-asked-questions.pdf).

Resource: Find the Medicare Advantage final rule at www. federalregister.gov/documents/2023/04/12/2023-07115/ medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program.