The Center for Medicare & Medicaid Services (CMS) released the Interoperability and Prior Authorization Final Rule (CMS-0057-F) on January 17, 2024 with the purposes of improving electronic exchange of health information and digitizing and standardizing prior authorization processes to achieve appropriate access to health records, for patients, providers, and payers, and to reduce delays and administrative burden while ensuring that patients remain at the center of their own care.
The final rule sets requirements for impacted payers to implement operational provisions from January 1, 2026 until January 1, 2027. The provisions include publicly reporting certain prior authorization annual metrics on their websites and providing a specific reason for denied prior authorization decisions regardless of the method used to send the prior authorization request. The impact payers include Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-Facilitated Exchanges (FFEs).
Within this context, the American Medical Association (AMA) published the CPT Assistant Special Edition in October 2024, providing guidance for reporting prior authorization-related activities performed by physicians or other qualified healthcare professionals with existing procedural codes; as part of the AMA initiative to standardize, automate and reduce physicians and qualified healthcare professionals administrative burden and fair reimbursement.
The AMA CPT Assistant Special Edition guides physicians and other qualified healthcare professionals on documenting work and time spent on prior authorization processes for services, supplies and medication. These activities may include extensive review and discussion with health plan representatives leading to physician attestation to affirm the appropriate plan of care. The activities performed are documented within evaluation and management (E/M) office or other outpatient codes.
The AMA CPT Assistant Special Edition presents two instances for reporting prior authorization-related activities; first, when activities are performed on the date of an E/M service, and second, when activities are performed on a date other than the E/M service date.
Prior Authorization-Related Activities Performed on the Date of an E/M Service or Visit
Prior authorization-related activities completed by a physician or other qualified healthcare professional on a date of an E/M visit are outlined in the description of procedure for mid-and-high level E/M office codes, for new patients 99203 to 99205 and for established patients 99213 to 99215.
The activities performed along with the clinical staff, to complete prior authorizations for medication and other orders, are documented in the E/M service, are considered part of the practice expense and may not be separately reported.
When the E/M service is reported based on Medical Decision Making (MDM), the prior authorization process may be impacted by changes in a patient’s treatment plan. The patient’s social determinants of health (SDOH) in terms of cost sharing, copayments and coverage considerations affect the patient’s treatment options. Therefore, when cost and coverage considerations affect MDM, the work performed by a physician or other qualified healthcare professional may be accounted for the Risk element of MDM in the moderate complexity level as a treatment significantly limited by SDOH.
When the E/M service is reported based on Total-Time, the time spent on prior-authorization related activities for a physician or other qualified healthcare professional include both face-to-face and non-face-to-face time on the day of the encounter and may be included in the sum of total time for the E/M service.
Prior Authorization-Related Activities Performed on a Date Other Than the E/M Service or Visit Date
Prior authorization-related activities performed by a physician or other qualified healthcare professional before and/or after direct patient care on the date of the E/M service, may be reported as prolonged evaluation and management service. Documenting prolonged services with code 99358 for first 60 minutes, and add-on code 99359 for each additional 30 minutes if all requirements are met. Code 99358 reports the total non-face-to-face time spent on a given date, even if the time spent on that date is not continuous. Prolonged services of less than 30 minutes on a given date are not separately reported.
The prolonged services codes 99358 and +99359 are both for reporting purpose only at this time. Medicare Physician Fee Schedule does not currently price these two codes, and codes are shown with APC status indicator N; no separate APC payment.
When a physician or other qualified health professional may need to dedicate time solely to complete special reports and signing forms related to prior authorization – such as an extension or renewal, formulary change, or a surgical pre-authorization form – the time spent on completing those forms may be reported with code 99080 – Special reports and forms. The scope of this work does not include time spent on the telephone or in other conversations.
The special reports and forms code 99080 is also for reporting purpose only at this time. Medicare Physician Fee Schedule does not currently price this code and is shown with APC status indicator B; bundled code.
The AMA CPT Assistant establishes code 99452 Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes, may not be reported by a physician or qualified healthcare professional for a prior authorization conversation with a health plan physician where the purpose of the conversation is whether a proposed treatment is covered by the patient’s insurance plan.
What Providers Can Do
- Audit documentation of evaluation and management services to determine whether prior authorization-related activities, when performed, are documented appropriately.
- Assess current payers’ contracts of reimbursable for related E/M office and outpatient codes.
- Assess clinical and administrative workflows for ensuring coding and billing are aligned with capturing and reporting prior authorization-related activities in E/M services before, during, and after patient direct care.
Windham Brannon’s Healthcare Consulting Practice can assist you to optimize revenue cycle processes and prepare for forthcoming changes to keep your organization on track to sustain patient engagement, mitigate regulatory risk and maintain payment integrity. For questions or more information, contact your Windham Brannon advisor today, or reach out to Denise Gaulin.
