Frequently Asked Questions About HBOT Reimbursement

Even though obtaining reimbursement for hyperbaric oxygen therapy (HBOT) requires the same skills as obtaining reimbursement for other wound care procedures, wound care professionals continue to have many questions about coding, payment, coverage, and the audit process for HBOT. As part of Today’s Wound Clinic’s special edition on HBOT, this installment of Business Briefs will address the most frequently asked questions related to HBOT reimbursement that many folks who are on staff at outpatient provider-based departments (PBDs) have for on-campus hospital-based facilities, as well as typical questions asked by physicians who supervise HBOT in the PBDs and their own office settings.  

Question No. 1: How many bills will the patient and the payer receive when the patient receives HBOT in a PBD? 

Answer: The patient and the payer will receive two bills: one from the PBD and one from the physician who supervised the HBOT. The PBD will typically report 4 units of G0277 to represent the number of 30-minute intervals of HBOT provided. The supervising physician will report 1 unit of 99183 because the definition of the HBOT supervision code is “per session.” Physicians should confirm that their claims do not report 4 units of 99183 to align with the 4 units of G0277 reported by the PBD: That upcoding will result in an overpayment and will most likely result in an audit.  

Question No. 2: What are the 2018 national average Medicare allowable rates for the PBDs and the physicians when they provide HBOT in a PBD? 

Answer: The 2018 national average Medicare allowable rates when HBOT is provided in a PBD are:

• For PBD G0277: $114.17 per 30-minute interval;
• For physician 99183: $113.04 per session.

Question No. 3: Is it true that Medicare will reimburse for HBOT provided in physician offices. If so, how should the physician code for the work, and what is the 2018 national average Medicare allowable rate for the physician work and for the use of the HBOT equipment?

Answer: Yes, Medicare now reimburses medically necessary HBOT provided in physician offices. The physician should code 99183 for supervising each session of HBOT and G0277 for each 30-minute interval of HBOT provided. The 2018 national average allowable rates when HBOT is provided in a physician’s office are:

• 99183 - $113.04 per session;
• G0277 - $86.04 per 30-minute interval.

NOTE: The national average allowable rate for G0277 in a physician office increased significantly in 2018 (from $49.89 in 2017 to $86.04).

Question No. 4: Since physician supervision for HBOT is reimbursed in both a PBD and a physician office, why does the place of service matter on a physician claim?

Answer: The answer is very simple. If the physician provided HBOT supervision in a PBD, but used the office place-of-service code, Medicare would overpay the physician and the physician would be in a repayment and/or an audit situation. Physicians should always report the correct place-of-service code on their claims. 

Question No. 5: Can nurse practitioners (NPs) supervise HBOT in a PBD or in a physician office?

Answer: The answer could be “yes” or “no.” Before NPs proceed with supervising HBOT, they should research how rules vary from state to state, from hospital to hospital, and from payer to payer. 

Reliable resources include: 1) state boards of nursing; 2) state practice and licensure laws for NPs; 3) medical staff bylaws of their place(s) of employment; 4) their personal medical staff credentials; 5) Medicare local coverage determination (LCD) and major payers’ medical policies pertaining to NP supervision of HBOT; and 6) Undersea and Hyperbaric Medical Society HBOT credential requirements. 

(NOTE: Individuals should know if they are in a “full practice and licensure,” “a reduced practice and licensure,” or a “restricted practice and licensure” state. The American Association of Nurse Practitioners’ website has an excellent map¹ that clearly shows the practice and licensure laws for each state. For example, the map shows that the District of Columbia allows full practice for NPs while Texas is a restricted-practice state.)

Question No. 6: Which diagnosis code(s) should be reported on a Medicare claim to guarantee reimbursement for HBOT?

Answer: Wound care professionals should always document (in the medical record) and report (on claims) the diagnosis code(s) that describe the patient’s condition. Diagnosis code(s) should not be reported just to ensure payment for a service/procedure/product. Medicare does have a national coverage determination (NCD) for HBOT that describes both the conditions that are covered and not covered by Medicare.² The diagnosis codes, including the new non-pressure chronic ulcer codes, that are covered by Medicare in 2018 are itemized in a spreadsheet that can be found online.³ (The zip file contains spreadsheets for a variety of NCDs. The HBOT spreadsheet is fourth from the top.) 

• Tab 1 of the spreadsheet contains ICD-10-CM diagnosis codes. When opening that spreadsheet, notice that one ICD-10 code satisfies HBOT medical necessity for some diagnoses. In other instances, two ICD-10 codes are required to satisfy medical necessity for HBOT. For example, the list identifies the diabetes and wound care codes that must be reported together to satisfy medical necessity. 
• Tab 2 of the spreadsheet contains the appropriate ICD-10 procedure code.
• Tab 3 of the spreadsheet specifies the rules that PBDs billing to Part A Medicare Administrative Contractors (MACs) or through the Fiscal Intermediary Standard System should follow. 

Wound care professionals who order and supervise HBOT for Medicare fee-for-service beneficiaries should download and/or print the spreadsheet of Medicare-covered diagnoses for reference. By studying this spreadsheet, wound care professionals will have complete transparency to the covered diagnoses for HBOT and whether one or two ICD-10 codes are required to satisfy medical necessity. If a patient lives with the diagnosis(es) listed on the spreadsheet, HBOT may be covered if all the other requirements of the MAC are met.

Although this question did not address private payers, Medicaid, etc., it is important to remember that they may or may not cover the same diagnoses that Medicare covers. Therefore, it is very important to conduct insurance benefit verification for all of these payers prior to providing HBOT to each patient.  

Question No. 7: Many chronic wound patients also live with numerous comorbidities that wound care professionals must manage. Should the diagnosis codes for these comorbidities be reported on claims even if they are not required to gain coverage for HBOT?

Answer: This is a very important question and one that wound care professionals should take seriously. Reporting pertinent comorbidities is beginning to impact more than coverage for HBOT: It may impact payment from some payers now and from other payers in the future.  That is good news because, in the past, wound care professionals were paid the same amount regardless of how many comorbidities they were managing for each patient. Let’s approach the answer to this question in three parts:

1. If the patient’s comorbidities pertain to managing the patient’s condition that requires the HBOT, wound care professionals should include them in the medical record and on the claim form. Remember, the diagnosis codes help “paint the picture” of the patient’s medical condition to the payer. 

2. In 2004, the Centers for Medicare & Medicaid Services (CMS) began using diagnosis codes to risk-adjust the payment to Medicare Advantage plans. Here’s a high-level overview of how this works: 

a) First the diagnoses codes are sorted into diagnosis groups. Then, the diagnosis groups are sorted into categories known as the CMS Hierarchical Condition Categories (CMS-HCCs).

• Related conditions are assigned to one category, and only the most serious is counted.
• A higher-ranked condition causes lower-ranked conditions in the same category to be ignored (with a few exceptions). 
• Unrelated conditions in different categories are both counted; the score is additive.

b) The condition categories are assigned a risk-adjusted factor (RAF):

• RAF score of 1 = patient who uses an average amount of resources.
• RAF score < 1 = patient who will use fewer than the average amount of resources.
• RAF score > 1 = patient with greater than average resource use.

c) Finally, three scores are added together to obtain the CMS-HCC score, which summarizes each beneficiary’s expected cost of care relative to other beneficiaries:

• Patient’s demographic score (age, sex, disabled status, etc.).
• RAF score for CMS-HCCs.
• Score for interactions between HCCs (only when a patient lives with a combination of two or more diseases, which would incur more costs than the sum of the individual diseases when they present alone).

3. Other payment systems are now using or are planning to use HCCs. Some of the most common payment systems are: Part D plans under the CMS-HCC prescription drug model, commercial payers under the U.S. Department of Health & Human Services HCC model, Alternative Payment Models (APMs), and the Merit-Based Incentive Payment System. Therefore, accurate documentation of the patient’s health status, as well as accurate coding of the patient’s primary diagnosis, secondary diagnosis, and pertinent comorbidities, is vitally important for coverage and adequate payment now and in the future.

Question No. 8: Over the last 10 years, attendees at Wound Clinic Business seminars have been told that PBDs should not bill for wound care services and HBOT on a monthly claim. Why is this?

Answer: The answer is very simple: The primary diagnosis that is covered by Medicare for wound care services/procedures/products often is different than the primary diagnosis that is covered by Medicare for HBOT. The claim form that the PBDs use only has one primary-diagnosis field. Therefore, a monthly claim could easily be denied for HBOT, if the diagnosis code for the wound care lands in the primary-diagnosis field of the claim. 

Question No. 9: Do any of the MACs have LCDs and/or articles pertaining to HBOT?

Answer: Yes, Noridian Healthcare Solutions has a published HBOT article, but it does not have a published LCD. Novitas Solutions and First Coast Service Options Inc.^® have published nearly identical LCDs. Their LCDs do not replace the HBOT NCD; they provide further guidance on such topics as: indications and limitations of coverage and/or medical necessity; description of standard wound care and required length of standard treatment that must precede initiation of HBOT; utilization guidelines (eg, frequency of wound evaluation during HBOT, when HBOT should be discontinued); guidelines relative to specific treatment conditions, which include criteria for diagnosis with expected frequency and duration of treatment; direct physician supervision requirements and description of “immediately available”; qualifications to provide direct supervision of HBOT; applicable codes to report for HBOT; and documentation requirements.

The following are documentation requirements itemized in both LCDs. Carefully read these requirements and ask yourself if the HBOT documentation in your medical record “paints the picture” outlined in these documentation requirements. 

1. All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (eg, complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. 
3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted Current Procedural Terminology/Healthcare Common Procedure Coding System code must describe the service performed. 
4. The medical record documentation must support the medical necessity of the services, as directed in this policy. 
5. Documentation that a trained emergency-response team is available and that the setting provides the required availability of intensive care unit services that could be needed to ensure the patient’s safety if a complication occurred. 
6. The documentation present in the clinical record must provide an accurate description and diagnosis of the medical condition supporting that the use of HBOT is reasonable and medically necessary. The medical documentation must include, but is not limited to:

• An initial assessment, which includes a history and physical that clearly substantiates the condition for which HBOT is recommended. This should also include any prior medical, surgical, and/or HBOT treatments. 
• Documentation of the procedure (logs), including ascent time, descent time, and pressurization level. There should be a treatment plan identifying the timeline and treatment goals. 
• Physicians’ progress notes that describe the physical findings, type(s) of treatment(s) provided, number of treatments provided, effect of treatment(s) received, and assessment of the level of progress made toward achieving the completion of established therapy goals. 
• Physician-to-physician communications or records of consultations and/or additional assessments, recommendations, or procedural reports. 
• Laboratory reports (cultures or Gram stains) that confirm the diagnosis of necrotizing fasciitis are required and must be present as support for payment of HBOT. 
• X-ray findings and bone cultures confirming the diagnosis of osteomyelitis are required and must be present as support for payment of HBOT. 
• Documentation to support the presence of gas gangrene, as proven with laboratory reports (Gram stain or cultures) and X-ray. 
• Documentation of date and anatomical site of prior radiation treatments.
• Documentation supporting date of skin graft and compromised state of graft site. 
• For diabetic wounds of the lower extremity, the Wagner classification of the wound and the failure of an adequate course (at least 30 days) of standard wound therapy must be documented at the initiation of therapy.

a) Documentation must include criteria and exam consistency to establish the diagnosis of a Wagner Grade III wound or higher.

b) Documentation of standard wound care in patients living with diabetic wounds must include: assessment of vascular status and documentation of correction of any vascular problem sufficient to impair wound healing in the affected limb; documentation of optimization of nutritional status; documentation of optimization of glucose control; documentation of debridement by any means to remove devitalized tissue; documentation of maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings; documentation of efforts for appropriate offloading; and documentation of necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there is no documentation of measurable signs of healing for at least 30 consecutive days post-optimization for healing. The medical record must include, at a minimum, a wound evaluation at least every 30 days during administration of HBOT therapy.

This author realizes that readers who are not in the Novitas or First Coast jurisdictions may be thinking, “These LCDs are not pertinent to me. Why should I read them?” The fact that these two LCDs are nearly identical is a good indication that the MAC medical directors talk to each other and often think alike. Along with the HBOT NCD and spreadsheets of covered diagnoses, these coverage documents can guide the development of HBOT care plans and should provide a clear picture of the in-depth documentation required to support HBOT utilization. Of course, if the other MACs (CGS,^® National Government Services,^TM Noridian, Palmetto GBA,^® and WPS^® Government Health Administrators) release HBOT LCDs, wound care professionals in the jurisdiction(s) covered by the new LCD should read and follow that LCD. In addition, wound care professionals in other jurisdictions should read any new LCDs to see if they provide further direction. The Novitas LCD is No. 35021.⁴ The First Coast LCD is No. L36504⁵ and the article is No. A55788.⁵ The Noridian -published HBOT article is No. A52916.⁶ 

Question No. 10: Some Medicare beneficiaries could benefit from HBOT, but their diagnosis is not on the list of covered diagnoses. Is there a way that the beneficiary can still receive the HBOT?

Answer: Yes, a Medicare beneficiary can purchase services/procedures/products that are not covered by Medicare. The wound care professional should explain to the patient that HBOT is covered for some medical conditions, but not for his/her medical condition. The wound care professional should present the beneficiary with an advance beneficiary notice of noncoverage (ABN), which should explain: 1) that Medicare may not pay for the HBOT, and 2) the estimated cost to the patient. The patient then selects one of three options listed on the ABN, and signs and dates the ABN:  

OPTION 1.  Language resembles: “I want the HBOT listed. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare summary notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less copays or deductibles.”

OPTION 2. Language resembles: “I want the HBOT, but do not bill Medicare. You may ask to be paid now, as I am responsible for payment. I cannot appeal if Medicare is not billed.”

OPTION 3. Language resembles: “I don’t want the HBOT.  I understand with this choice I am not responsible for payment and I cannot appeal to see if Medicare would pay.” The wound care professional should place one copy of the ABN in the patient’s medical record and give the other copy to the patient. If the patient selects option 1 or 2, the wound care professional should append the appropriate ABN modifier to the HBOT code on the claim.  

Many wound care professionals have told this author that they don’t offer HBOT to Medicare beneficiaries who do not live with the indications covered in the NCD. Interestingly enough, medical professionals in other specialties tell this author that they believe it is their obligation to inform their patients about technology that may be beneficial for their medical condition, even if it is not covered by Medicare. They usually have ABNs readily available for those instances. Wound care professionals might want to rethink their position on this topic and make the ABN process a routine part of their patient encounters. The CMS’ ABN form and instructions can be found online.⁷ 

Question No. 11: I do not practice in one of the states that participated in the HBOT prior authorization demonstration project. However, I heard that numerous patients in PBDs did not receive positive prior authorization from their MAC medical director. What were the major stumbling blocks?

Answer: Like all new programs, CMS’ Prior Authorization Model for Non-Emergent Hyperbaric Oxygen Therapy demonstration project had a “rocky” beginning for both the PBDs and MACs in Illinois, Michigan, and New Jersey. The MACs had a variety of processing and consistency issues at the beginning. Most of those were improved.
Keep in mind that the HBOT prior authorization project did not create new documentation requirements. It simply enforced the NCD and LCD/article requirements that were already in place. Throughout the demonstration project, this author spoke privately to PBD professionals in these three states. They reported that their prior authorization denials could have been minimized: 

1. If they had obtained critical supporting documentation from referring practitioners, if they: 1) performed standard wound care, and/or 2) ordered and completed diagnostic tests before the patient presented to the PBD. That work, and the test results, must be included in the Medicare beneficiary’s medical record as supporting documentation for HBOT and should be supplied to the MAC in the HBOT prior authorization request. 
2. If documentation included the patient’s medical condition and comorbidities. 
3. If PBDs and physicians had carefully read the HBOT NCD and the MAC’s LCD, and had incorporated the coverage guidelines into their plan of care and documentation. In fact, many PBDs and physicians stated that “reading coverage rules and medical policies is the job of the coders and billers.” This statement always surprises this author, who continually educates wound care professionals that coverage policies are their “playbook for success.” 
4. If they had ensured that the HBOT medical records contained the following documentation:

• HBOT history and physical,
• legible, signed HBOT physician order,
• prior pertinent medical/surgical procedures and/or previous HBOT
• prior antibiotic therapy and surgical intervention or any adjunctive treatment simultaneously rendered,
• laboratory reports (culture or Gram stain) confirming the diagnosis of actinomycosis,
• X-ray findings and/or bone cultures confirming the diagnosis of chronic refractory osteomyelitis, and what forms of medical and surgical management were tried and failed,
• procedure notes, and
• procedure logs, including ascent time, descent time, and pressurization level. 

At the end of these discussions with PBD professionals, nearly everyone said (paraphrasing), “please educate other PBDs who are not in the demonstration project about the importance of refining their HBOT processes, orders, and documentation to prevent medical reviews and denials.” The Prior Authorization Model for Non-Emergent Hyperbaric Oxygen Therapy ended, as scheduled, on Feb. 28, based on date of service. The independent evaluation of the model is ongoing. Results of the demonstration project will be available once completed.

Question No. 12: Is it true that the MACs have begun to include HBOT on their target lists for the new CMS Targeted Probe and Educate (TPE) program?

Answer: The May 2018 Business Briefs column will provide an overview of the TPE program. Until then, this author has found HBOT on the TPE target list of one MAC: WPS. n

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board.  

References

1. State Practice Environment. AANP. Accessed online: www.aanp.org/legislation-regulation/state-legislation/state-practice-environment

2. National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29). CMS. 2017. Accessed online: www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?ncdid=12

3. Zip File CR10318. CMS. Accessed online:  www.cms.gov/medicare/coverage/determinationprocess/downloads/cr10318.zip

4. Local Coverage Determination (LCD): Hyperbaric Oxygen (HBO) Therapy (L35021). CMS. 2015. Accessed online: www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=35021 

5. Local Coverage Determination (LCD): Hyperbaric Oxygen (HBO) Therapy (L36504). CMS. 2016. Accessed online: www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?docid=L36504

6. Local Coverage Article: Hyperbaric Oxygen and E/M codes (A52916). CMS. 2015. Accessed online: www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52916&ver=2&docid=A52916

7. FFS ABN. CMS. 2017. Accessed online: www.cms.gov/medicare/medicare-general-information/bni/abn.html