The Expanding Scope of Prepayment Review for Hyperbaric Oxygen Therapy

In 2016, prepayment review for Hyperbaric Oxygen Therapy (HBOT) Healthcare Common Procedure Coding System code G0277 was started by Medicare Administrative Contractors, including Noridian Healthcare Solutions, Novitas Solutions, Palmetto GBA,^® and WPS^TM Government Health Administrators. Some reviews were targeted reviews; others were more expansive in scope. Prepayment review allows Medicare to review claims before payment for a service already rendered in order to reduce improper payment rates. In 2017, Novitas announced prepayment review expansion to include Region JH, which encompasses Arizona, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, and Indian Health and Veteran Affairs.  What follows is a brief outline of updates:

1. Specific guidance for HBOT charting and documentation based on what we learned from prior authorization morphing into the prepayment review process. It’s important to note that each date of service must be accompanied by all relevant documents. (This may mean sending multiple documents multiple times.) For example, for every day of service there will be a request for codes 99183 and G0277. For each request, the relevant documents must be sent separately. Additionally, a copy of the history and physical, orders, letter of medical necessity, etc. must be sent with each separate date of service requested.

a. Signed physician orders for HBOT documenting gas, treatment depth, duration of treatment, air breaks, descent and ascent rates, and expected number of treatments must be included. (The order would look like this: HBOT order 100% oxygen at 2.4 ATA [atmospheres absolute] for 90 minutes, with 10-minute air break at 45 minutes, and a descent and ascent rate of 1-3 psi [pounds per square inch]/minute [depending upon the patient’s ability to clear]. Expected treatments - 40.)

b. If there’s any question about the legibility of one’s signature, providers may submit a signature log or an attestation statement in the Additional Development Request response.

c. Blood sugars must be ordered if they are done for chamber-side screening in those living with diabetes. 

d. Any interventions must be ordered (eg, nasal spray, dietary supplementation).

e. Documentation of physician’s attendance and supervision of HBOT.

i. Physician says he/she was present.

ii. The technician or nurse also says the physician was present.

f. HBOT log documenting length of treatment, complications, and “documentation to support the entire body was exposed to the oxygen under increased atmospheric pressure and administered in a chamber.”

g. When asked for medical records for a single date of service, include:

i. history, physical, and expert opinion note on why the patient requires HBOT;

ii. the medical necessity for HBOT, listing interventions that have failed;

iii. length of time of symptoms;

iv. impact on quality of life;

v. if the patient lives with an associated ulcer or wound, the wound care notes around the requested date of service;

vi. the hyperbaric patient needs to be evaluated for progress at least every 30 days;

vii. results of all testing/services billed.

2. “Inpatient-only” conditions made by the Centers for Medicare & Medicaid Services from Novitas, First Coast Service Options Inc., and the draft version of Noridian local coverage determinations for HBOT. 

a. The following conditions are expected to be provided in the inpatient-only setting due to the acute and critical nature of the disease, concomitant conditions, and need for correlation with other acute, invasive, or monitoring services: 

i. gas gangrene;

ii. sequela of acute peripheral ischemia (including reperfusion conditions of arterial embolism and thrombosis);

iii. reimplantation or crush injuries of the extremities; 

iv. necrotizing fasciitis;

v. air embolisms;

vi. carbon monoxide/cyanide poisoning. 

b. Therefore, HBOT for these services in an outpatient or non-acute care setting would be considered not reasonable and necessary conditions that Medicare has made “inpatient only.” 

Helen B. Gelly is emeritus medical director of Hyperbaric Physicians of Georgia and chief executive officer of HyperbaRXs.