Understanding & Responding to Prepayment Reviews for Hyperbaric Oxygen Therapy

Appropriate response to records requests requires knowledge of the prepayment review process. This article offers guidance to HBOT providers in wound care.

The prior authorization project for hyperbaric oxygen therapy (HBOT) launched in May 2014 by the Centers for Medicare & Medicaid Services (CMS) has been implemented fully. All three states (Illinois, Michigan, and New Jersey) are participating. The result has been a substantial reduction in HBOT utilization. (Reports vary from 40-80% rates of denials). It’s not surprising that some prior authorization states number among the 11 states with the highest number of fraud and error-prone providers (Florida, California, Michigan, Missouri, North Carolina, Ohio, Pennsylvania, Texas, New York, Louisiana, and Illinois).

CMS has considerable experience in using prior authorization projects to curb perceived overutilization and potential fraud and abuse. By their nature, these projects are limited in geographic scope. They can be expanded, but a national implementation requires some level of congressional intervention, and this is challenging in today’s political environment. However, traditional methods of auditing payment can be used instead (prepayment and post-payment review). Post-payment review and takebacks have taken numerous forms.¹ Prepayment review allows Medicare to review claims before payment for a service already rendered in order to reduce improper payment rates. The implementation of a prepayment audit is within the scope of all Medicare intermediaries and presents challenges to physicians and hospitals. Noridian Healthcare Solutions LLC, the intermediary that covers California, recently implemented a “Provider on Review” (POR) program for HBOT provided in a hospital outpatient department (HOPD). Although this is currently limited to HOPDs, the “creep” to physician payment is unknown. In the prior authorization projects, if the hospital does not receive prior approval, the physician payment is also affected. What does this mean to providers and HOPDs? The steps involved have many parallels. The reasons for flagging a provider may include billing for a service that has been identified as “at risk” for fraud/abuse and overutilization. HBOT has unfortunately acquired that designation. Initial screening of claims is done using National Correct Coding Initiative (NCCI) and medically unlikely edits (MUEs). NCCI edits identify improper coding. MUEs limit the number of units of service within a given day that would be seen as “medically necessary.” For example, the MUE for 99183 (physician supervision of HBOT) is 1; the MUE for G0277 (30-minute segment of HBOT) is 5. Patients on a twice-per-day treatment schedule would be automatically flagged as “unlikely” and require medical review. A recent educational session offered by Noridian identified the steps that part of the POR reviews regarding HBOT. Providers will be notified by letter following the prepayment review and an additional documentation request (ADR) will be sent. Providers must respond within 45 days. If no response is received, the denial is made for “non-receipt of medical records.” If the claim is denied (or if a provider is dissatisfied with the determination), a request for redetermination must be sent within 120 days. The Medicare Administrative Contractor (MAC) redetermination review process allows for 60 days to provide response. Those providers who are not satisfied with the outcome have 180 days to file a reconsideration request with the qualified independent contractor (QIC) working with the MAC. At this level, all supporting documentation that can be foreseen as needed in the provider’s defense (including literature, position statements, and complete relevant medical records) must be submitted. The QIC then has 60 days to respond. If that response is considered to be unfavorable, the provider may go to a third level of appeal — an administrative law judge (ALJ) appointed through the U.S. Department of Health and Human Services. At this level, providers cannot easily submit additional information. Ultimately, there are five levels of appeal: I - Redetermination by the MAC; II - Reconsideration by a QIC; III - Hearing before an ALJ; IV - Review by the Medicare Appeals Council; V - Judicial review by a federal district court (see Figure 1). The appeals process is described in Business Briefs. 

Unfavorable Outcomes

Common reasons for unfavorable HBOT decisions include the lack of a legibly signed physician order for the therapy, which must include the delineation of treatment pressure, rate of descent/ascent/air breaks, planned duration of therapy, and frequency per day. Also, blood sugars must be ordered. The treatment note must clearly show the length of time of the total hyperbaric treatment, the appropriate treatment diagnosis, documentation proving that the physician was available and present during therapy, and must be signed. Legibly. The initial ADR must have supporting documentation sent along with the treatment record, which would include the initial evaluation that addresses the documentation of conventional care, lack of response, and goals for HBOT.

However, having all that documentation is not necessarily a formula for immediate success. There is considerable variability in the quality of the reviewers, and the review process can be arduous depending on the medical director and the interpretation of the national coverage determination (NCD), local coverage determination, or article. Having had the dubious distinction of being under prepayment review for the better part of 2015, this author has more than anyone’s fair share of stories to tell.

Example Responses

The following quoted comments are taken verbatim from responses to redeterminations. The italicized content represents editorial comments from this author.

• “The provider is billing G0277 x 4. According to the NCD for hyperbaric oxygen therapy (20.29), treatments greater than two services per day must have documentation supporting medical necessity for increased frequency … The claim is paid for two treatments.”

Perhaps the medical reviewer was looking at the MUE for 99183 and not G0277? In any event, nowhere in the NCD does it reference frequency of treatment.  

• “There is no Wagner Grade III classification or higher. The documentation only verifies one service according to the NCD for hyperbaric oxygen therapy (20.29). The use of HBOT is covered as an adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. The documentation fails to support the service. Therefore, the denial is upheld.”

Well, it’s pretty difficult to have a Wagner Grade III ulcer when the patient has radiation cystitis … however he had a comorbidity of diabetes and the diabetic foot ulcer (DFU) requirements are being conflated with the delayed effects of radiation. … But the responses get better ...

• “This 69-year-old female with soft tissue necrosis and history of radiation received one dive … and was billed and paid with service 99183 ... there is no additional service documented for this patient on this date.”

“Educational note to provider: There is no recorded Wagner scale of wound on the HBOT document as required per NCD Manual (Publication 100-03), Chapter 1, Part 1, Section 20.29: HBOT”
Educational note to reviewer: There is no Wagner scale of the wound in osteoradionecrosis of the mandible. Wagner refers to the ulcers of a dysvascular, neuropathic diabetic foot — and only the foot. However, the tendency for the requirements of the DFU to be reflected in all diagnoses is evident.

• “70-year old female patient performed on … Our Medical review staff states that after review of the submitted documentation, it is determined that the documentation does not support the medical necessity … The use of HBOT is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care … The documentation reflects this is a patient with a left nasal flap. However, the documentation only supports that this wound has been present for eight days. Therefore, the denial is upheld.”

The indication for compromised flap/graft is urgent and does not qualify for 30 days of standard wound care … But here again, the tendency is to paint all indications with the DFU brush.

Confusion at the beginning of any implemented process is inevitable. These examples are more a reflection of the perception that every hyperbaric indication requires 30 days of standard care and that the Wagner grading system for DFUs can be applied to any and every part of the body. The hyperbaric community needs to pay attention to what is being documented in the denials in the prior authorization project as well as the Noridian POR. To help and encourage wound clinic providers to share their experiences with each other, Today’s Wound Clinic is offering an online forum (click here) to help ensure the standards that we are judged by are accurate, that we are following trends in misinformation so that they may be corrected.

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

Reference

1.  Larson-Lohr V. Understanding the post-payment review process. TWC. 2015;9(8):16-18.