Business Briefs: Hyperbaric Oxygen Therapy Reimbursement Reminders for a Successful 2010

Disclaimer: Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the 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.

  Should we or should we not offer Hyperbaric Oxygen Therapy (HBOT)?” is a question that hospitals throughout the country frequently ask. Once physicians and administrators review the clinical efficacy of this adjunctive therapy, the final decision is often based on issues surrounding reimbursement for the HBOT service. To address reimbursement issues that lead to financially viable HBOT services, this author reached out to two (2) HBOT reimbursement experts who assist hospitals with HBOT documentation, coding, coverage, billing, and auditing issues on a daily basis:

  • Julie Orzali, CHFP, MS, CHAS, CMRS, Vice President of Reimbursement for Diversified Clinical Services (DCS). Jacksonville, Florida (www.diversifiedcs.com); email address jorzali@diversifiedcs.com; and phone number (904) 625-4268. Julie has over 20 years of healthcare finance and hospital revenue cycle experience including physician reimbursement. DCS is the nation’s largest wound management company specializing in wound care and hyperbaric services.

  • David Walker, President and CEO of Intellicure, Inc., The Woodlands, Texas (www.intellicure.com); email address dwalker@intellicure.com; and phone number (800) 603-7896. David personally managed 4 highly successful wound and hyperbaric centers before forming Intellicure, an ambulatory electronic medical records company. Intellicure’s flagship product is IntelliTrak which has provided clinical documentation, practice management, and quality reporting to advanced wound and hyperbaric centers for 15 years.

  Schaum: Julie, when you begin managing existing HBOT outpatient departments, is it true that documentation and reimbursement issues are two of the highest hurdles? If so, will you please share how you go about ensuring that coding, billing, and reimbursement are accurate and efficiently implemented?

  Orzali: Yes. When we review existing hyperbaric departments not managed by DCS, we find that numerous hospitals do not bill for these services correctly. This is usually due to the lack of reimbursement specialists assigned to manage the business side of HBOT. When we are contracted to assume those responsibilities, a DCS reimbursement specialist 1) provides continuous training, 2) communicates payer rule updates, and 3) conducts periodic audits / reviews of claims submitted, payments received and documentation compliance with payer policy guidelines. Facilities who manage their own HBOT departments should also perform similar reimbursement work. The best tips I can offer to the readers are the major steps we follow to ensure a financially viable department.

  We begin by confirming all the procedure codes that should be used with all the major payers in that geographical area. Then we work with the Charge Description Master (CDM) director to 1) include all the appropriate HCPCS, procedure, and revenue codes on the HBOT department’s CDM, and to 2) ensure that the procedure and revenue codes correctly bill to the various payers. To complete the CDM, we provide our hospital partners with Medicare APC rate updates before January 1st of each year. Because physicians are an integral component of HBOT, we also provide them with detailed coding information.

  Next we review the private payers’ HBOT medical policies, Medicare’s HBOT National Coverage Determination (NCD), and the appropriate Medicare Administrative Contractor’s (MAC) Local Coverage Determination (LCD), if one exists. We remind the coders to review all the pertinent medical policies for the specific ICD-9-CM codes that are covered by each payer, as well as the documentation that is required by each payer to support the services that are billed. The coders for hospitals and physicians should review the HBOT documentation and assign the appropriate ICD-9-CM codes on all hospital and physician claims.

  We also provide detailed coverage information to the physicians so they can adhere to the payer-specific requirements necessary to bill for their participation in the HBOT services. If the physician’s and facility’s documentation in the medical record does not meet the payer’s medical policy requirements, the HBOT facility and the physician may receive payment, but risk future requests for repayment.

  NOTE: DCS continually reviews private payers’ medical policies and Medicare LCDs and immediately communicates implications to the departments we manage and to the physicians who work in them. Our ongoing education includes the need to ensure complete charting /documentation and coding of hyperbaric claims. We continually educate our hospital partners and advise them when these services can be billed. This minimizes denials and repayment requests. If you do not have this kind of outside support, I recommend that you assign someone to review these policies in detail to understand how they may impact the hospital and the physicians.

  Finally, we work with the program director to update the HBOT facility’s charge sheet; it must include the HCPCS codes that are relevant to the separately billable products, the procedure codes that are relevant to the clinic visits and procedures, and the ICD-9-CM diagnosis codes that specify the medical necessity for the work performed in the HBOT facility. If incorrect codes are used, the service will be denied by the payers.

  Schaum: Does Medicare cover all medical indications for hyperbaric treatments?

  Orzali: No. Medicare has published a National Coverage Determination for Hyperbaric Oxygen Therapy (NCD 20.29) which provides reimbursement for fifteen (15) covered conditions which have been indicated as beneficial through research:
    1. Acute Carbon Monoxide Intoxication
    2. Decompression Illness
    3. Gas Gangrene
    4. Gas Embolism
    5. Acute Traumatic Peripheral Ischemia
    6. Crush Injuries
    7. Progressive Necrotizing Infections (Necrotizing Fasciitis)
    8. Acute Peripheral Arterial Insufficiency
    9. Cyanide Poisoning
    10. Osteoradionecrosis
    11. Soft Tissue Radionecrosis
    12. Actinomycosis
    13.Chronic Refractory Osteomyelitis
    14. Preparation and Preservation of Compromised Skin Grafts
    15. Diabetic Wounds of the Lower Extremities.

  The first eight (8) covered indications are emergent conditions which are normally, but not always, performed in an inpatient setting. HBOT departments and physicians should review their MAC’s specific LCD and pertinent private payer policies to determine the exact ICD-9-CM codes that are covered. As discussed in your Fall 2008 In Business column (www.todayswoundclinic.com/inbusiness-fall-2008), the covered ICD-9-CM codes vary among the MACs and the private payers. NOTE: There are also many highly publicized and experimental uses of HBOT which are not reimbursed by Medicare and private payers. DCS and our managed facilities do not provide services that are not medically necessary or are not administered under a physician-directed protocol. We do not recommend or endorse the use of HBOT to treat disorders that are not approved by the Food and Drug Administration (FDA).

  Schaum: What happens if an HBOT department or physician does not use the covered ICD-9–CM codes?

  Orzali: The claim will be denied and the providers will not be reimbursed. In some instances the providers can bill the patient if they provided the patient with an Advance Beneficiary Notice of Noncoverage (ABN) prior to providing the service and the patient agreed to receive the service and to personally pay for the service. If the providers did not provide an ABN, they often are not permitted to bill the patients for HBOT that is not deemed medically necessary.

  NOTE: In some cases the HBOT was performed for a covered diagnosis, but the physician’s documentation did not clearly allow the hospital and physician coders to assign a covered ICD-9-CM diagnosis code. This usually happens when the physician did not review their MAC’s LCD or the private payer’s medical policy.

  Schaum: Do the private payers (e.g. Blue Cross) reimburse HBOT for all of the 15 Medicare covered indications?

  Orzali: Not always. The private payers’ policies may vary from state-to-state and even from plan-to-plan. They may/may not cover HBOT for the same indications as are covered by Medicare. For example: Some of the Blue Cross plans follow the published guidance provided by the Undersea and Hyperbaric Medical Society (UHMS) and cover HBOT for thermal burns. Prior to rendering HBOT, the HBOT centers and physicians must review each private payer’s HBOT medical policy to determine the indications that are covered as well as the indications that they deem to be experimental, investigational, unproven, and not covered.

  Schaum: Can a HBOT department bill Medicare for a terminated hyperbaric therapy service?

  Orzali: In order to bill Medicare for a hyperbaric treatment using CPT code C1300 the patient must be in the chamber for at least 16 minutes. If the treatment lasted 15 minutes (chamber door-closed to door-open) or less, HBOT departments usually cannot bill Medicare for the treatment. NOTE: Most private payers follow Medicare guidelines on this topic, but HBOT departments and physicians should check with each private payer to determine if their policy is consistent with Medicare’s payment policy. For example, facilities and physicians may be allowed to bill an evaluation and management (E&M) service in specific circumstances.

  Schaum: Over the last two years, the Centers for Medicare & Medicaid Services (CMS) have clarified their requirements for direct supervision in hospital-owned outpatient departments. Do the direct supervision rules also apply to hospital-owned HBOT outpatient departments?

  Orzali: Yes, Medicare and other private payers require physician supervision and attendance when the patient is receiving HBOT. This means that the physician must be immediately available when supervising this service. They cannot be engaged in another activity that would prevent them from attending to the patient’s immediate needs.

  Some MACs may allow non-physician practitioners or podiatrists to supervise HBOT. This is another reason that facilities and physicians should review their MAC’s web site to determine if an LCD exists for HBOT. If an LCD is available, facilities and physicians should review it frequently since MACs revise policies often and with minimal notice.

  Schaum: When the physician provides direct supervision for HBOT, what code(s) should the physician use?

  Orzali: For Medicare and most private payers, the appropriate code to use for physician supervision and attendance is 99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session. However, physicians are strongly advised to review their MAC’s LCD (if one exists) and/or the private payer’s HBOT medical policy before they perform the service since there may be exceptions or the rules may have changed. NOTE: The physician can only bill 99183 once per HBOT session.

  Schaum: How does Medicare reimburse hospital outpatient departments for outpatient HBOT?

  Orzali: HBOT treatments are reimbursed for C1300, via the Ambulatory Payment Classification (APC) system, separately in a hospital outpatient department for Medicare beneficiaries when medical necessity has been met. Because C1300 is per each 30-minute interval, it may be necessary to bill for more than one (1) interval (depending on the length of time that the patient is in the hyperbaric chamber). The rules for appropriate billing of hyperbaric services are included in the CMS Claims Processing Manual. The 2010 calendar year APC payment, unadjusted for wage index, is $107.04 per 30-minute segment. HBOT departments should check with their finance department or their management company to learn their actual APC payment that is adjusted for the hospital area wage index.

  Schaum: I receive many inquiries asking if HBOT departments can bill Medicare separately for HBOT provided for Medicare inpatients. What is the correct answer?

  Orzali: Unfortunately the answer is no. The Medicare prospective payment system reimburses hospitals a flat rate per case based on the Diagnosis Related Group (DRG) to which the patient’s diagnosis (es) tracks. The hospital receives one payment for all services provided to the Medicare beneficiary during his/her inpatient stay – including HBOT.

  Schaum: Julie, thank you for sharing your valuable coding, payment, and coverage insights with our readers. Do you have any parting thoughts for our readers?

  Orzali: HBOT departments and their affiliated physicians often have a difficult time keeping up with ongoing changes pertaining to HBOT coding, coverage, documentation, billing, and payment. They should assign one or more reimbursement specialists to help them manage this very important part of their business. If that is not possible, they may want to consider using a wound management company to assist them.

  Schaum: David, I am interested in providing the readers with real-life information about HBOT coding and billing errors that are typically made by HBOT outpatient departments. Will you share information that you have learned before and after implementing the Intellicure system at HBOT and wound care outpatient departments throughout the U.S.?

  Walker: Yes, the Intellicure electronic medical record (EMR) automatically calculates the appropriate charges for wound care and hyperbaric services, and integrates with the hospital billing system. During implementation of the Intellicure EMR, we thoroughly review the hospital outpatient department’s Charge Description Master (CDM) to make sure that the hospital is using appropriate coding and billing practices. As a result, we have identified many instances in which facilities (some of which have been open for many years) are coding and billing HBOT incorrectly.

  Schaum: When you review the CDM, what is the number one HBOT-related problem that you have identified?

  Walker: Even though CDMs are capable of handling different procedure codes and revenue codes for the major payers, many program directors do not take advantage of this CDM feature. The major HBOT facility procedure code is an example of this problem.

    • Medicare and some private payers require the HBOT facility to code and bill C1300 Hyperbaric oxygen under pressure, full body, per 30 minute interval.

    • Many other private payers require the HBOT facility to code and bill 99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session

  As you can see, these codes are not simple substitutes for each other. They are not interchangeable because C1300 is billed in 30 minute increments (a single hyperbaric treatment typically is reported with 3 or 4 billed units) and 99183 is billed per session (a single hyperbaric treatment is reported with 1 billed unit). Therefore, the CDM must be set up with both procedure codes and must bill the correct code depending on the patient’s insurance.

  Schaum: If the covered HBOT procedure code is not correctly billed based on the patient’s payer, the facility could face non-payment, overpayment, or underpayment. In addition, this can cause internal auditing problems. Do you really find these problems happening on a routine basis?

  Walker: Yes, in our experience 40% of HBOT programs use C1300 and 99183 inappropriately. Here are a few examples:

    • The HBOT facility performs a hyperbaric treatment, consisting of four 30-minute increments, for a Medicare beneficiary. The facility uses the correct C1300 code on its Medicare claim, but inappropriately bills a unit of 1. In this case, the HBOT facility only receives 25% of the Medicare allowable for the work they actually performed.

    • The HBOT facility performs a hyperbaric treatment, consisting of four 30-minute increments, for a patient with private insurance that requires the procedure code 99183. The facility uses the correct code 99183 on the claim, but inappropriately bills for 4 units. In this case, the claim is often denied and the facility does not understand “why” because they know they used the correct procedure code. In some cases, the claim is incorrectly paid for the 4 units rather than the correct unit of one. Later the private payer often requests a repayment if they conduct an audit.

    • Some HBOT facilities only monitor their denied claims. Therefore, they often do not catch the Medicare underpayments when they make the mistake of billing only 1 unit of C1300. Likewise, they do not catch private payer overpayments when they make the mistake of billing 4 units of 99183 rather than 1 unit.

    • Some HBOT facilities get denied by all private payers because they use the code C1300 instead of 99183.

  Schaum: David, thank you for sharing the common HBOT coding and billing errors that you typically find. Do you have a parting comment for the readers?

  Walker: Yes, be sure that you set up your CDMs to handle both procedure codes C1300 and 99183 for the appropriate payers. Also, be sure that your CDMs do not still include the old HBOT procedure codes 99181 and 99182. We often find the HBOT facility’s charge sheet has the correct C1300 and 99183, but the CDM has 99181 and 99182 listed for HBOT treatments. In those cases all their claims are usually denied by both Medicare and private payers. Because 99181 and 99182 were deleted several years ago, they should no longer be listed in CDMs.

  Summary: Julie and David have made it perfectly clear that HBOT reimbursement and retention of monies received after an audit hinge on 1) documenting all services performed, 2) selecting the appropriate diagnosis and procedure, codes, 3) following coverage policy guidelines, 4) billing correctly, and 5) conducting self-audits to catch and remedy honest errors. Because understanding coverage policies is such an integral component of the financial success of an HBOT service, Table I is provided to assist you in locating and reviewing your MAC’s LCDs. Each reader is highly encouraged to download, print, read, and share the correct LCD information with all members of your team – medical director, physicians, HBO technicians, coders, billers, CDM director, corporate compliance director, etc. Please note that many of these LCDs have attachments and/or articles – be sure to download and review all of these documents. If a MAC only published Articles or Frequently Asked Questions, Table I lists those links. CAUTION: The information in Table I was current on the day this article was submitted for publication. Be sure to assign someone to monitor your MAC’s web site on a monthly basis for updates, new drafts, etc. The Medicare LCDs and private payer medical policies should provide the blueprint for your HBOT program’s financial success.

Kathleen D. Schaum, MS, is President of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling (561) 964-2470 or through her email address: kathleendschaum@bellsouth.net.

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