HBOT Documentation Paramount, Especially With Prior Authorization Looming

Information regarding coding, coverage, and payment is provided as a service to readers. Every effort has been made to ensure accuracy of all information. However, HMP Communications and the authors do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

  Unfortunately, a lack of appropriate implementation of payment processes by qualified healthcare professionals (QHPs) and hospital-based outpatient wound care departments (HOPDs) in general may be causing further (and often more stringent) reimbursement regulations. As you continue reading this column, you will learn of the unintended consequences that have resulted on the part of the wound care industry’s general reluctance to not thoroughly implement two processes related to reimbursement as it pertains to hyperbaric oxygen therapy (HBOT). Let’s take some time now to discuss HBOT coding, payment, and coverage processes that should be part of one’s daily wound care practice.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
RELATED CONTENT
Business Briefs: Let NCDs and LCDs Guide the Way to HBO Reimbursement
Business Briefs: Hyperbaric Oxygen Therapy Reimbursement Reminders for a Successful 2010
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Covered Diagnosis Codes

  In the fall 2008 and April 2010 issues of Today’s Wound Clinic, “Business Briefs” emphasized the need for specific HBOT diagnosis coding and adequate documentation, and this author has personally educated attendees about this topic at all Wound Clinic Business seminars for the past few years. QHPs and HOPDs should have specific guidelines about the diagnoses that are covered by Medicare for HBOT. The national coverage determination (NCD) for HBOT (20.29) provides a list of covered diagnoses by name. Several Medicare Administrative Contractors (MACs) have written local coverage determinations (LCDs) and articles that provide specific ICD-9-CM codes that they will cover. QHPs and HOPDs that provide HBOT should carefully review the covered diagnoses in the NCD and the specific ICD-9 codes in the LCD of the MAC that processes their claims.

  While consulting with a major teaching institution, this author was recently told by both QHPs and the HOPD that NCDs and LCDs are “for the coders, and that coders should choose the diagnosis code that they know will lead to positive coverage and payment.” Actually, nothing is further from the truth. Only QHPs can diagnose diseases. QHPs do not necessarily have to memorize diagnosis codes, but they must understand the level of specificity that is required by the covered code descriptions. Therefore, QHPs should review the current HBOT NCD and pertinent LCD/article to gain an appreciation for the specificity of covered ICD-9 codes.

  In addition, the Centers for Medicare & Medicaid Services (CMS) has already published the future effective NCDs and LCDs with covered ICD-10 codes that will take effect Oct. 1, 2015. The ICD-10 codes for the HBOT NCD can be found in the revision history dated May 2014 and located at the bottom of the NCD. QHPs should review the ICD-10 codes that will be covered and immediately begin to diagnose their patients to that level of specificity. Do not wait until 2015.

  CMS has also required any MACs that currently have LCDs to publish future effective LCDs with ICD-10 codes. (See Table 1.)

Correct Procedure Coding

  C1300 Hyperbaric oxygen under pressure, full-body chamber, per 30-minute interval is still the code that HOPDs should use to report HBOT work to Medicare. HOPDs should verify the units of service on their claims represent the number of 30-minute intervals that were provided to each patient. CAUTION: C1300 is not necessarily the code that HOPDs should use when submitting claims to payers other than Medicare. When the HOPD conducts insurance benefit verification before performing the procedure, the HOPD should also verify if the payer recognizes C1300 or 99183 (see below). Note that the units of service for 99183 are per session, not per 30-minute intervals.

  99183 Physician attendance and supervision of HBOT, per session is still the code that QHPs use to report their HBOT supervision to all payers. QHPs should verify that their claims do not contain more than 1 unit per encounter because the description of 99183 is “per session,” not per 30-minute intervals. NOTE: Some private payers may not recognize C1300 for HOPD work and may require HOPDs to report their work with 99183. In this case, the HOPD must report the charge “per session.”

Medicare Allowable Payment Rates

  The Medicare allowable payment rates for both the HOPD and QHP have changed slightly over the past seven years. (See Table 2.) QHPs often ask why they are not paid more for this very important work. Always remember that payment is based upon the relative value units (RVUs) that are assigned to medical and surgical procedure codes. Those RVUs begin with the Relative Value Update Committee (RUC) surveys received from specialty societies. When QHPs receive RUC surveys for HBOT or for any service/procedure, they should carefully describe the level of work they perform when they complete the surveys. They also should discuss this work with specialty society representatives to the RUC committee. The units of service and the charges on HOPDs’ Medicare claims play a major role in Medicare HOPD payment rates two years later. (See the September 2014 “Business Briefs.”) Therefore, HOPDs should place priority on 1) maintaining their charge sheets and charge description masters and 2) auditing their claims to be sure the units of service and the charges actually appear on the claims as intended.

Medicare Coverage

  This author ceases to be amazed at the number of QHPs and HOPDs that do not have copies of and have not personally read 1) Medicare’s NCD and 2) their MAC’s LCD pertaining to HBOT. QHPs and HOPDs must personally read the Medicare LCDs that pertain to the work they perform and the medical policies of the major private payers that insure their patients. Remember the motto that this author and reimbursement educator constantly uses: You cannot play the game without your playbook! Previous governmental audits indicate HBOT has a high potential for improper payments and raises concerns about beneficiaries receiving medically unnecessary care.

  A) In calendar year 2000, an Office of the Inspector General report on HBOT found: $14.2 million (of the $49.9 million allowed charges for outpatient hospitals and physicians) was paid in error – beneficiaries received treatments for either noncovered conditions or documentation did not adequately support HBOT. An additional $4.9 million was paid for treatments deemed to be excessive, and lack of testing and treatment monitoring raise quality of care concerns.

  B) In 2008, documentation was the major cause of claims denials for HBOT:
    • For the minutes of HBOT descent time, breaks, and ascent time;
    • To support that diabetic patients fulfilled three NCD qualifications:
      1. Patient lives with type 1 or 2 diabetes and has a lower extremity wound due to diabetes.
      2. Patient has a wound classified as a Wagner grade III or higher.
      3. Patient has failed an adequate course of standard wound therapy.
    • To support HBOT treatment billed for Healthcare Common Procedure Coding System code C1300.

  C) In 2010, documentation was still a major cause of HBOT claims denial and repayment.

  D) On May 23, 2014, HBOT providers received a CMS “wake-up call” that was a consequence of inadequate HBOT documentation. To address CMS’ growing concern that beneficiaries are receiving non-medically necessary, nonemergent HBOT, CMS announced plans to initiate a new prior authorization demonstration program for nonemergent HBOT in Illinois, Michigan, and New Jersey. The six nonemergent medical conditions that must receive prior authorization are:
    1) Preparation and preservation of compromised skin grafts (not for primary management of wounds).
    2) Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management.
    3) Osteoradionecrosis as an adjunct to conventional treatment.
    4) Soft tissue radionecrosis as an adjunct to conventional treatment.
    5) Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment.
    6) Diabetic wounds of the lower extremities in patients who meet the following three criteria:
      a) Patient lives with type 1 or 2 diabetes and has a lower extremity wound that is due to diabetes.
      b) Patient has a wound classified as Wagner grade III or higher.
      c) Patient has failed an adequate course of wound therapy as defined in the NCD.

  Prior authorization is a process through which a request for provisional affirmation of coverage is submitted for review before service is furnished to a beneficiary and before a claim is submitted for payment. Prior authorization helps ensure that applicable coverage, payment, and coding rules are met before services are rendered. Some insurance companies, such as TRICARE, certain Medicaid programs, and the private sector already use prior authorization to help ensure proper payment before the service is rendered. Illinois, Michigan, and New Jersey were selected for the initial prior authorization demonstration process because of their high utilization and improper payment rates for these services.

  Beneficiaries in these states had the highest average sessions by total expenditures. CMS will test whether prior authorization helps reduce expenditures while maintaining or improving quality of care. CMS believes using prior authorization will help ensure services are provided in compliance with applicable Medicare coding, payment, and coverage rules before services are rendered and claims are paid.

  Prior authorization will not create new clinical documentation requirements. Instead, it will require the same information necessary to support Medicare payment, just earlier in the process. Prior authorization allows providers and suppliers to address issues with claims prior to rendering services and to avoid an appeal process. This will help ensure that all relevant coding, coverage, and clinical documentation requirements are met before the service is rendered to the beneficiary and before the claim is submitted for payment. In other words, the HBOT prior authorization demonstration process will allow all relevant documentation to be submitted for review prior to rendering services. CMS or its contractors will review the request and provide an affirmative or negative decision. During the prior authorization, CMS Medicare review contractors will ensure the requests are consistent with all existing applicable regulations, NCD and LCD requirements, and other CMS policies. Clinical staff assigned to medical review and trained to ensure consistency will handle the prior authorization requests. They will employ private sector standards in the prior authorization program such as:
    • responding to prior authorization requesters within 10 business days (not calendar days) of receipt of an initial prior authorization package,
    • providing responses that are specific about missing information, and
    • giving providers an opportunity to resubmit the prior-authorization package for re-review. During resubmission the contractor will have 20 business days for review.

  NOTE: A provisional affirmative prior-authorization decision may affirm up to 36 courses of HBOT treatment in a year. NOTE: A provider, supplier, or beneficiary may request an “expedited review” when the standard timeframe for making a prior authorization decision could jeopardize the life or health of the beneficiary. MACs will make reasonable efforts to communicate a decision within two business days of receipt of all applicable Medicare-required documentation. As these models are for nonemergent services, CMS expects requests for “expedited reviews” to be extremely rare.

  If providers receive affirmative prior-authorization decisions, they can submit their HBOT claims with the affirmative decisions. MACs will list the prior authorization tracking number on the decision notices. This tracking number must be submitted on the claims.

  Those claims will be paid as long as all other coverage requirements are met. If providers receive negative prior-authorization decisions, unlimited resubmissions are allowed. However, these subsequent requests will be processed within 20 business days. Claims submitted with a negative prior authorization will be denied. If providers choose to forego prior authorization and submit claims without prior authorization, their claims will undergo prepayment review. The prior-authorization decision will address the facility payment for the HBOT service. If a facility has no prior authorization or a negative prior authorization, the associated physician claim will be subject to medical review. CMS announced that when the prior-authorization demonstration process begins, providers in Illinois, Michigan, and New Jersey who choose to utilize the process may send requests to their MACs via mail, fax, or through the Electronic Submission of Medical Documentation system (www.cms.gov/esmd).

  CAUTION: CMS has not yet announced a start date for the prior-authorization demonstration process that will be conducted in Illinois, Michigan, and New Jersey. HBOT QHPs and HOPDs in these states should monitor their MAC’s website for implementation information and for the start date of the process. Those who do not practice within these states should take this demonstration process as a “wake-up call.” Demonstration programs can be and have been quickly enacted throughout the country. Since the prior-authorization demonstration process and the current payment and auditing of HBOT claims will focus on QHPs’ documentation, now would be a good time for all QHPs to sharpen their HBOT documentation.

  To emphasize the level of detail that must be included in the documentation, this author has compiled the documentation requirements found in several current LCDs. (See Table 3.) All should monitor their MAC’s current LCD for revisions and should watch for new draft LCDs and new future effective LCDs posted on the Medicare coverage database.

For author info and disclosures, see page 4.