Correcting Common Bad Habits That Cause Medicare Denials and/or Repayments for HBOT

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Due to the recent Medicare hyperbaric oxygen therapy (HBOT) prior-authorization initiative, the numerous Medicare HBOT audits, and the costly HBOT repayments, some physicians and other qualified healthcare professionals (QHPs) and hospital owned outpatient wound management provider-based departments (PBDs) are leery about using HBOT. Like all wound management services, procedures and products, HBOT should be used for the right person, for the right reason, at the right time, and supported with the right orders/documentation/coding. Unfortunately, some bad habits have led to claims denials. Worse yet, these bad habits have led to incorrectly paid claims that later caused audits, repayments, and fines.

To help prevent these bad habits from causing claims denial and repayments, this article itemizes a few bad habits that should be broken or avoided.

Physicians/QHPs and PBDs providing and billing Medicare for HBOT that was not ordered. Because HBOT is often administered daily for numerous weeks, physicians/QHPs mistakenly think that one order covers all the HBOT sessions. When Medicare conducts pre-payment or post-payment reviews, they typically deny or request repayment for dates of HBOT treatments that were not specifically ordered.

This bad habit should be easy to break if physicians/QHPs and PBDs are reminded that each visit, to the physician/QHP office and to the PBD, for HBOT treatments is a unique visit. Just like an order is required for each return visit to physician/QHP offices and to PBDs for other services such as debridement, total contact cast, etc., so is an order required for each return visit for additional HBOT treatments.  

Physicians/QHPs and PBDs providing HBOT for non-covered diagnoses. Because wound management professionals sometimes feel pressured to keep their HBOT chambers in-use, they provide HBOT to patients who do not have a diagnosis that is covered by Medicare. This happens when HBOT is provided before the practice verifies if each patient’s diagnosis is on the list of covered diagnoses on the HBOT National Coverage Determination (NCD).

This bad habit of not conducting insurance benefit verification, which should include reviewing pertinent NCDs and local coverage determinations (LCDs), is easily remedied by establishing a process for verifying insurance benefits and reviewing coverage guidelines in NCDs and LCDs before performing all HBOT treatments. The NCDs and LCDs should be read by all members of the clinical team (including the physicians/QHPs) and the revenue cycle team. If the patient’s physician/QHP believes the patient could benefit from HBOT, which is not covered by Medicare, the physician/QHP should present the patient with an Advance Beneficiary Notice of Noncoverage (ABN). If the patient wishes to have the HBOT even though it is not covered by Medicare, the patient can sign the ABN and agree to personally pay for the HBOT.

Physicians/QHPs reporting incorrect number of HBOT supervision units on claims. When physicians/QHPs supervise HBOT in PBDs, they often incorrectly report 4 units of the HBOT supervision code 99183 on their Medicare claims. This happens because the PBDs typically bill 4 units of G0277 to represent the number of 30-minute intervals of HBOT provided. When the physicians/QHPs see that the PBDs billed 4 units of G0277, they mistakenly think they should also bill 4 units of 99183.

This bad habit of overbilling the Medicare program can easily be corrected. The physicians/QHPs should be educated that the definition of the HBOT code G0277, used by the PBD, is per 30-minute interval, while the definition of the HBOT supervision code 99183, used by the physicians/QHPS, is per session. Therefore, physicians/QHPs should never bill more than 1 unit of 99183 per session.

If physicians/QHPs provide HBOT in their offices, they should report 1 unit of the supervision code 99183 per session. In addition, they also should report the HBOT code G0277. In their offices, the physicians/QHPS will typically bill for 4 units of G0277 because the code definition is per 30-minute interval.

Physicians/QHPs and PBDs submitting claims for HBOT treatments that are not adequately documented in the patients’ medical records. Physicians/QHPS and PBDs do not always thoroughly document the items required by the HBOT NCDs and LCDs and by the Medicare Administrative Contractors (MACs) that process their claims. If their claims are not subject to a pre-payment review and correct codes and units are reported, the claims may be paid. That payment gives the physicians/QHPs and PBDs a false sense of security because their MAC paid them despite their lack of documentation. Then when post-payment audits or Targeted Probe and Educate Audits are conducted, the inadequate HBOT documentation results in large repayments. In nearly every case, the claims denials and repayments could have been avoided with appropriate HBOT orders, specific diagnosis codes, and explicit documentation that addressed every item in the NCD, LCD, and guidelines provided by the MACs.

Correction of this bad habit of inadequate HBOT documentation should be a high priority for all physicians/QHPs and PBDs. They should personally read and study the NCD and LCD/Articles that pertain to HBOT and should incorporate all coverage requirements into their plans of care, their orders, and their documentation templates.

For an excellent example of the details required for HBOT documentation, physicians/QHPs and PBDs should review the documentation checklist that Noridian Healthcare Solutions released on February 8, 2019.¹ Following are the main documentation topics that are included on the checklist (read the entire checklist for all the documentation details):

• Legible handwritten physician and/or clinician signatures
• Valid electronic physician and/or clinician signatures
• Physician or Non-Physician Practitioner (NPP) order for date of service, if applicable
• Initial HBOT evaluation/consultation by the physician or NPP
• Documentation supporting HBOT covered condition(s) for NCD for Hyperbaric Oxygen Therapy (20.29)
• Progress notes
• HBOT treatment plan
• HBOT dive logs/treatment records
• Wound treatment records or wound flow sheets supporting measurable signs of healing
• Diabetic wound(s) required documentation
• Standard diabetic wound care therapy documentation required prior to starting HBOT
• Evaluation and Management (E&M) documentation, if billed on same date of service
• Itemization of services    
• Advance Beneficiary Notice of Noncoverage (ABN), if applicable

Physicians/QHPs and PBDs should look for similar guidance documents from their MACs.

Conclusion

If any readers have been practicing these bad habits, now is a great time to break the habits by establishing good documentation habits that “paint the picture” of your patients’ needs for HBOT. Physicians/QHPs and PBDs should be able to 1) continue providing HBOT for patients who need it, 2) document the medical necessity for the HBOT, and 3) submit HBOT claims with correct diagnosis (or diagnoses) and procedure codes.  

When physicians/QHPs and PBDs read the hyperbaric oxygen NCD and LCD documentation guidelines, review all directions provided by their MACs (like the checklist provided by Noridian Healthcare Solutions), and develop good ordering and documentation habits, they should significantly reduce claims denials and repayments when they provide HBOT for the right person, for the right reason, and at the right time.

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.

1. Hyperbaric Oxygen Therapy (HBO) Services Documentation Requirements. Available at https://med.noridianmedicare.com/web/jea/topics/documentation-requirements/hyperbaric-oxygen-therapy-services . Last accessed Aug. 18, 2019.