Business Briefs: Let NCDs and LCDs Guide the Way to HBO Reimbursement

  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.

  Q: We are considering adding hyperbaric oxygen therapy (HBO) to our existing hospital owned outpatient wound care department. Can you confirm if Medicare has a National Coverage Determination (NCD) for HBO therapy? If so, do any Medicare contractors also have Local Coverage Determinations (LCDs) pertinent to HBO therapy?

  A: Medicare implemented NCD for Hyperbaric Oxygen Therapy (20.29) on July 1, 1997, and revised it several times since then: the October 19, 2000 revision clarified that “preparation and preservation of compromised skin graft” is not for primary management of wounds; the December 27, 2002 revision expanded coverage for the treatment of diabetic wounds of the lower extremities in patients that meet three criteria. For more information on the NCD visit (www.cms.hhs.gov/mcd/results.asp?show=all&t=200810162257).

  The NCD clearly outlines the 1) medical conditions that are covered and reimbursed by Medicare (See Table I) [NOTE: Statue exempts coding from NCDs—providers must refer to LCDs for covered ICD-9-CM diagnosis codes]; 2) circumstances when HBO therapy will be covered as adjunctive therapy to non-healing diabetic wounds; 3) wound evaluation frequency during administration of HBO therapy; and 4) non covered conditions. (See Table II).

  In addition to the NCD published by Medicare, several Medicare contractors have released LCDs to clarify the NCD. The LCDs often provide:
    a) Expanded definitions of HBO therapy
    b) Primary functions of HBO therapy
    c) Explanation that references to ‘physicians’ include non-physicians such as nurse practitioners, clinical nurse specialists, and physician assistants who may verify, order, and establish the plan of care for HBO therapy services as authorized by State law
    d) Locations where HBO therapy may be covered
    e) Revenue codes typically used to report HBO therapy (for providers who bill HBO services to fiscal intermediaries)
    f) Relevant CPT® and HCPCS codes
    g) ICD-9-CM codes that support medical necessity. (Note: Statue allows LCDs to list actual ICD-9-CM codes that are covered.) Some LCDs cover more diagnoses than required by the NCD. Some examples are:
      1) 526.4 inflammatory conditions of jaw and 595.82 irradiation of cystitis are covered by Palmetto GBA, and National Government Services.
      2) 909.2 late effect of radiation is covered by Palmetto GBA, National Government Services, First Coast Service Options, Tri Span Health Services, and Wisconsin Physician Services.
    h) Documentation requirements
    i) Utilization guidelines relative to covered conditions including:
      1) Duration of therapy
      2) Physician supervision requirements

  The following are some LCDs that were in existence at the time of publication of this journal. NOTE: This is not a complete list and the LCDs may not be current by the time the journal is printed. Providers are encouraged to obtain the LCDs pertinent to them: www.cms.hhs.gov/mcd

  Medicare contractors often provide additional guidance to the LCD via Articles and Attachments. Hyperlinks to these documents can be found at the bottom of the LCDs under the headings of Related Documents or LCD Attachments. Providers should be sure to open and review the documents because they offer additional guidelines for topics such as: 1) Advance Beneficiary Notification (ABN), 2) Modifier usage, 3) Appropriate place of service codes, 4) Claims submission, 5) Bill types, 6) Calculation of 30 minute interval units, 7) Billing requirements for patients with diabetic wounds of the lower extremities, 8) Billing for evaluation and management codes on the same day as an HBO treatment.

  The following are some examples of Articles and Attachments that were available at the time of this journal publication:
    A) BlueCross and Blue Shield of Arkansas provides an Article for Hyperbaric Oxygen (HBO) therapy for the Treatment of Diabetic Wounds of the Lower Extremities
    B) BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administration) provides 1) Article for Hyperbaric Oxygen Therapy for the Treatment of Diabetic Wounds of Lower Extremities, which outlines various available CMS coverage documents; 2) Article for Hyperbaric Oxygen Therapy: New Guidelines for coverage, which reviews expanded coverage for diabetic wounds of the lower extremities; and 3) Article for Billing HCPCS C1300 Coverage (Hyperbaric Oxygen Services) Database
    C) First Coast Service Options provides a Coding Guidelines attachment
    D) National Government Services provides 1) a Supplemental Instructions Article and 2) the Medical Decision Memo for Hyperbaric Oxygen Therapy for Hypoxic Wounds and Diabetic Wounds of the Lower Extremities
    E) Noridian Administrative Services provides 1) an Article for Hyperbaric Oxygen and E/M Codes; and 2) an Addendum Article for Hyperbaric Oxygen Therapy
    F) PalmettoGBA provides an Article for Hyperbaric Oxygen Therapy Assigned ICD-9 Codes ~NCD, which lists every ICD-9 code that justifies medical necessity for HBO therapy covered by PalmettoGBA
    G) TrailBlazer Health Enterprises provides an Article that describes 1) standard wound care in patients with diabetic wounds; 2) reasons for denial of HBO therapy payment; 3) non covered conditions, and 4) additional coding guidelines.

  Q: What is the correct CPT® code for billing HBO therapy to Medicare – C1300 or 99183?

  A: Physicians should use the following code when they perform the service in an office, inpatient hospital, hospital owned outpatient department, and independent clinic: 99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session

  NOTE: The 2008 CPT® Current Procedural Terminology book states “Evaluation and Management services and/or procedures (eg, wound debridement) provided in a hyperbaric oxygen treatment facility in conjunction with a hyperbaric oxygen therapy session should be reported separately.”

  Hospital owned outpatient departments paid by the Ambulatory Payment Classification (APC) system should use the following code: C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

  Q: I have heard that Medicare denies many HBO Therapy claims based on lack of medical necessity. Can you explain some of the common coding errors?

  A: To answer that question, the author interviewed Richard “Dick” E. Clarke. Clarke is currently the President of National Baromedical Services in Columbia, South Carolina (www.baromedical.com). Clarke is also the program director at the Hyperbaric Medicine Service and Wound Healing Center at Palmetto Health Richland Hospital in Columbia, South Carolina; the Director of The Baromedical Research Foundation; and the Administrator of the Diving Preferred Provider Network.

  Schaum: Our readers are hoping that you can help them understand common diagnosis coding errors that lead to claim denials.

  Clarke: Certainly one of the most common coding problems leading to claim denials relates to the treatment of soft tissue radionecrosis. Medicare’s Hyperbaric Oxygen (HBO) Therapy NCD mandates ICD-9-CM code 990 Effects of radiation, unspecified. This code is not anatomic specific. Rather, it is a generic code and is expected to be applied to all soft tissue radiation damaged sites (bladder, rectum, skin, larynx, etc.). The one anatomic exception to ICD-9-CM code 990 is the mandible. This bony lesion is coded in accordance with the NCD as ICD-9 Code 526.89 Other specified diseases of the jaws; osteoradionecrosis. See Table III for other specific anatomic radiation induced injury ICD-9-CM codes.

  The problem arises at the hospital coder/physician business office level. Coders are taught to code to the highest degree of specificity. Therefore, coders are unlikely to select the generic 990, despite Medicare’s urging. If, in the consultation report, the hyperbaric physician attributes radiation-damaged tissue to an anatomic site, as one would expect, coders are going to search for the code that is representative of that site. And plenty of anatomic-specific coding options exist. If the coder prevails, which is invariably the case, Medicare and most private insurers are likely to deny the claim as not medically necessary. Arguments that the claim should be coded in accordance with Medicare’s hyperbaric NCD have frequently fallen on deaf ears. Coders will counter that their license is at risk if they fail to code to the highest degree of specificity.

  What to do? Without a solution, the condition that currently represents in excess of 50% of all of hyperbaric medicine’s utilization will likely go unpaid. Some hospitals have gone as far as to question whether to open their hyperbaric medicine service in the first place because of this dilemma.

  The solution is to file claims for soft tissue radionecrosis using both primary and secondary codes. One code is used to represent the NCD requirement; the other is to describe the anatomic site. We have not experienced claim payment problems when using these dual codes and it does not appear important the order in which code is used.

  One final observation regarding this situation relates to the Medicare contractors’ LCDs. Hyperbaric Oxygen providers and coders have pointed out that a better (more accurate) option to ICD-9 Code 990 exists and that is 909.2 late effect of radiation because it precisely describes what HBO therapy is employed to treat.

  ICD-9-CM code 990 implies a whole body exposure. It is used in the setting of accidental acute exposure to radiation that might occur at a nuclear power plant or in the radiation oncology department. In their LCDs, some Medicare contractors include coverage for 909.2 in addition to 990. Therefore, it is important to determine which diagnosis code is covered by your Medicare contractor prior to submitting claims for soft tissue radionecrosis.

  Schaum: Thanks for helping us understand why some Medicare contractors have added 909.2 to their list of covered diagnosis codes. Are there any other areas of ICD-9-CM coding that are problematic

  Clarke: A second common reason for claim denial by commercial insurers and post-payment demands for repayment by Medicare is the toe amputation. HBO therapy is frequently employed to support the healing of toe amputation sites, thereby minimizing the risk of the ‘whittling away’ syndrome, particularly in the diabetic patient.

  The key to meeting ‘medically necessary’ insurance company compliance is the manner in which the resulting amputation site defect was addressed. Commonly, the amputation site is left open and anticipated to heal by secondary intention. This option is frequently chosen when any concern exists regarding viability of the amputation level. Alternatively, the amputation site may be closed primarily using a rotational skin flap. Finally, and rarely, is primary closure by approximation of the skin bordering the defect, if sufficient tissue remains available.

  In every one of the above closure options patients have undergone supportive HBO therapy. Only one option, however, meets Medicare’s ‘medical necessity’ standards, and the standards of most of the others who purchase health care. That is the skin flap procedure. HBO therapy is employed when flap viability is in question. It is not used to support the amputation site; per se.

  Interventions that support amputation site healing are coded as 997.60 or 997.62 if signs of infection are present. These are not, however, medically necessary codes for HBO therapy. The medically necessary code for HBO’s flap support is ICD-9 Code 996.52 Mechanical complication of graft; skin graft failure or rejection. Code 996.52 has been used by many hyperbaric providers when the open amputation/secondary intention healing option has been employed. This is an incorrect use of the code and non-payment is the common result.

  Another coding and billing problem associated with the use of HBO therapy for toe amputation support is the use of ICD-9 Code 996.52, when the amputation is closed by re-approximation of the surrounding skin. This is not by definition a skin flap. Host skin has simply been brought back to the site it previously occupied. Claim denial is also likely.

  HBO therapy may be of benefit in toe amputations regardless of how their closure is addressed. However, it is only the support of a compromised skin flap that represents a ‘medically necessary’ indication by those who purchase health care. One can always seek ‘pre-approval’ from commercial insurance companies for amputation support when a skin flap has not been employed. A demonstration of local hypoxia per transcutaneous oximetry immediately proximal to the amputation site suggests the likelihood of a healing complication.

  Insurance companies may well recognize their financial risk of healing compromise, which include repeated hospitalizations and surgeries. They may, therefore, be prepared to authorize a brief course of HBO therapy in order to overcome local hypoxia via hyperbaric oxygen-induced angiogenesis providing reversibility of hypoxia can be demonstrated. A course of 14-25 hyperbaric treatments can be expected to normalize tissue oxygen states to the point that local host competency is re-established. Standard wound care is then likely to be successful in prompting the wound on to complete healing in the majority of cases.

  Schaum: Thank you for educating us about the correct diagnosis for toe amputations. Do you have any advice about below knee amputations (BKA)?

  Clarke: A common problem area is the BKA. HBO therapy is frequently consulted when primary closure dehiscence occurs or if other signs suggest that viability at this amputation level is in question. The ability to maintain a BKA verses its conversion to an above knee amputation is well appreciated for its enormous physical, social and economic implications.

  For HBO therapy to be deemed medically necessary the amputation site must have been closed or loosely approximated with a skin flap. Typically, the surgeon will maintain some of the skin overlying the posterior calf that is then rotated anterially to affect coverage.

  Hyperbaric billing problems exist on two fronts. First is the claim submitted for a compromised amputation – ICD-9 code 997.60 or 997.62. The insurer is likely to deny benefits as not ‘medically necessary’. Benefits are also likely to be denied if the BKA is of the ‘open’ guillotine type. Primary closure may not have been attempted, perhaps due to acute concerns about healing potential. If skin has been rotated to create flap coverage, then change code 997.60/62 to 996.52 and resubmit the claim. No reimbursement is likely for the hyperbaric treatment of an open BKA, unless a pre-authorization request from a commercial insurance company was approved.

  A second problem here is a payment denial for a compromised BKA when 996.52 is used correctly. Some insurers have and continue to argue that the rotation of skin to close the amputation site is not actually a skin flap. This position is inconsistent with published positions within the plastic surgery literature, definitions in medical textbooks and prevailing surgical opinion. Any such payment denials should be appealed, and beyond the ‘in-house’ insurance company level, if initially unsuccessful. Such appeals are invariably successful without the need to resort to the legal system. Less successful is an appeal for payment denials secondary to the hyperbaric treatment of a saphenous vein donor site dehiscence, following a CABG procedure. Here, the original skin was used and brought back to its surgical pre-operative position. This is not, by definition, a skin flap. The resulting dehiscence can best be defined as a problem wound. Few insurance companies would recognize HBO therapy as a medically necessary therapeutic option unless a skin graft or skin flap was used to cover the defect.

  Schaum: Dick, Thank you for helping the readers avoid these common diagnosis code selection errors.

  Q: Can you provide us with some major problems that are identified during Medicare audits?

  A: Yes, the major reimbursement repayments are due to a lack of documentation:
    a. For the minutes of HBO decent time, breaks, and ascent time
    b) To support that the diabetic patients fulfilled all three NCD qualifications:
      1) Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes
      2) Patient has a wound classified as a Wagner grade III or higher; and
      3) Patient has failed an adequate course of standard wound therapy
    c) To support HBO treatment billed for HCPCS code C1300

  SUMMARY: All current and future HBO Therapy providers are encouraged to obtain and review the HBO NCD and any Medicare contractor’s LCDs, Articles, and/or Attachments. These documents serve as the base guidelines for reimbursement of HBO services.

  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.