Prior Authorization & Nonemergent HBOT: Update for Providers in Outpatient Wound Care

CMS officials believe they can reduce HBOT spending while maintaining or improving quality of care by ensuring services are provided in compliance with Medicare coverage and payment rules before the claims are paid. This article provides an update on these reporting procedures.

The Centers for Medicare & Medicaid Services (CMS) has implemented a prior authorization model for nonemergent hyperbaric oxygen therapy (HBOT) in the states of Illinois, Michigan, and New Jersey. CMS officials have also openly stated that the goal of this project is to determine whether or not prior authorization reduces Medicare expenditures. It is the position of CMS that it can reduce spending on HBOT services while maintaining or improving quality of care by ensuring services are provided in compliance with Medicare coverage and payment rules before the claims are paid. CMS officials argue that prior authorization does not create new clinical documentation requirements because the information required should be no different than would be required if the record went to post-payment review. In the view of CMS, prior authorization allows providers to address issues with claims prior to rendering services, thus avoiding an appeal process. The information required to support Medicare payment must be sent to the Medicare Administrative Contractors (MACs) in each of the affected states:

• Illinois facilities serviced by A/B MAC Jurisdiction 6 NGS (National Government Services),

• Michigan facilities serviced by A/B MAC Jurisdiction 8 WPS (Wisconsin Physician Services), and

• New Jersey facilities serviced by A/B MAC Jurisdiction L Novitas Solutions Inc.

Prior authorization was not implemented on the same date in all three jurisdictions because the details of the review process took some time to establish. However, all three are now active. (Details are available at: www.cms.gov.) The Undersea and Hyperbaric Medical Society and the Association for the Advancement of Wound Care have been collecting information regarding the reasons for denial of HBOT under the prior authorization process. Today’s Wound Clinic is also accepting feedback from wound care clinicians who are interested in submitting information pertaining to the reasons given for denied treatments. Some wound care clinics and hospitals have experienced challenges in getting their treatments authorized. The list below is not an exhaustive list of reasons for HBOT denials. (Charting deficiencies can be corrected and resubmitted).

Reasons for HBOT Denials During Prior Authorization

A) For a patient with a failing flap: HBOT was denied because the tissue at risk was not a skin graft. (“Flap” is not in the language of the national coverage determination.)

B) For patients living with a diabetic foot ulcer:

1) HBOT was denied because there was no documentation of 30 days of standard wound care.

2) HBOT was denied because there was no documentation of vascular screening (physical exam is insufficient) or documented action to correct peripheral artery disease (PAD) if present.

3) HBOT was denied because, if action was taken to correct PAD (as a result of an abnormal vascular screen), a subsequent vascular screening was needed to determine response to vascular intervention.

4) HBOT was denied because hemoglobin A1C was not recorded at the time of initial visit and then after 30 days.

C) HBOT was denied on a general patient assessment/visit due to incorrect charting, inconsistent location of wound (eg, left leg improperly documented as “right leg.”)

D) HBOT was denied because there was no HBOT physician order within a patient’s chart (for each daily treatment).

NOTE: HBOT prior authorization must be requested in segments (meaning, the 30-minute segments that comprise the typical HBOT protocol for one’s facility).

Caroline E. Fife is chief medical officer at Intellicure Inc.; executive director of USWR; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders. Helen Gelly is emeritus medical director of Hyperbaric Physicians of Georgia and chief executive officer of HyperbaRXs.