ALERT! “Targeted” Pre-payment review of Hyperbaric Oxygen Therapy to occur in Iowa, Kansas, Missouri, and Nebraska
The Medicare Administrative Carrier “WPS” has announced a Targeted Medical Review (TMR) of 100 claims for hyperbaric oxygen therapy in the states of Iowa, Kansas, Missouri, and Nebraska.
A similar POST-payment Targeted Medical Review (TMR) of Hyperbaric Oxygen Therapy (HBO) has been completed for Indiana providers of hyperbaric treatments containing “high risk diagnoses” such as diabetes and arteriosclerosis. This probe sampled multiple providers and per the MAC, the [billing] error rates were in excess of 90%.
We knew that pre-payment review was expanding. This is different from the HBOT “Prior-authorization” program, currently still active in only 3 states (MI, IL, NJ). To understand this process better, read Helen Gelly’s excellent article in Today’s Wound Clinic by following this link: http://www.todayswoundclinic.com/articles/expanding-scope-prepayment-review-hyperbaric-oxygen-therapy. Also, if you want to understand what POST payment review is, read this TWC article by Valerie Larson-Lohr: http://www.todayswoundclinic.com/articles/understanding-post-payment-review-process
Prior Authorization vs. Pre-Payment Review:
Under prior authorization, BEFORE rendering the hyperbaric service, you are required to send in your records and the MAC has 10 days to make a determination as to whether HBOT is medically indicated and will be covered for the indication requested. Pre-payment review happens AFTER you have provided the hyperbaric service and are submitting the claim for HBOT treatments already given. The MAC can request medical records for review before they pay the claim. While the MAC has an unlimited amount of time to review the records before deciding whether they will pay for the services you have already provided, this review is usually completed within 30-45 days. If your claim is denied for lack of medical necessity, you may ask for a “redetermination” which usually takes about 60 working days. If denied again, you may request “reconsideration” which is an independent audit process that takes another 60 days. Please note that by this time, your HBOT claims have gone unpaid for more than 5 months. The next step is to request a hearing before an administrative law judge. How long it takes for this to happen depends on how busy the docket is, but it can be months. If denied before the judge, you then have the option of hiring an attorney and going to court.
It is important for hyperbaric providers to watch for any medical record requests coming from a MAC as part of a prepayment review. If these requests are sent directly to the hospital medical records department and languish there, after 45 days the claim is simply denied for lack of responsiveness. If this targeted review goes badly, it could result in an expansion of pre-payment review.
The prepayment review process could actually be a far greater threat to the future of hyperbaric medicine because claims for services already rendered can go unpaid for six months or longer as they work through the review and appeal process. This delay in payment could spell financial disaster for a hyperbaric operation.
Carefully read the documentation requirements below. If you HBOT charts do not contain the elements listed, you need to get your documentation in order immediately. This is not a drill.
The language below was taken directly from the article (see link at the bottom):
When WPS GHA identifies a provider or service as being at risk, the potential error is validated with a prepayment probe [italics CF] review. The probe sample of potential problem claims is used to validate the hypothesis that such claims are being billed incorrectly or in error. [italics CF] Conducting a probe review ensures that medical review activities are targeted at identified problem areas. WPS GHA requests a sample large enough to provide confidence in the result, but small enough to limit administrative burden.
Your facility will be notified of the selected claims per your normal Additional Documentation Request (ADR) process. This may be via a mailed ADR letter and/or Direct Data Entry (DDE). Submit the requested medical record information within 45 days. Before you send the requested records, we suggest you double-check the accuracy of your submitted claim.
Be sure to place a copy of your ADR on top of each record submitted.
Be sure to place a copy of your ADR on top of each record submitted.
- Documentation to support the dates of service billed Treatment records (Dive sheets)
- Signed order for HBO services
- Documentation to support services are for treating a condition as described in CMS Pub 100-03, Medicare National Coverage Determination (NCD) Manual, Chapter 1, Coverage Determination, Section 20.29, Hyperbaric Oxygen therapy.
- The documentation submitted may include, but is not limited to: History and Physical that clearly describes the condition for which HBOT is recommended
- Physician progress note(s) that support all adjunctive therapies provided to the beneficiary in the treatment of the diagnosed condition
- Laboratory and pathology report(s) if applicable
- Radiology reports if applicable
- Vascular studies if applicable
- Documentation to support (minimum) 30 days of failed conservative treatment(s) of wound with wound measurements if applicable
- Operative and/or procedure reports related to the diagnosis if applicable
- Date and anatomical site of radiation treatment if applicable
- Prior antibiotic administration record to support chronic condition if applicable (i.e. chronic osteomyelitis)
- HBOT procedure log(s) to include ascent time, decent time and pressurization level
- Direct physician supervision
- Assessment of condition (minimum) every 30 days during the HBOT
- For condition where HBOT is covered when there is a threatened loss of function, limb, or life, the documentation must support the condition.
- The use of HBOT is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 – days of treatment with standard wound therapy.
- Advance Beneficiary Notice of Non-coverage (ABN) if applicable
The CMS Internet-Only Manual (IOM) Publication 100-03, Chapter 1, Part 1, Section 20.29, Hyperbaric Oxygen Therapy
Questions and Answers
Can non-physician practitioner/physician extenders write HBO orders?
Non-physician practitioner/physician extenders may write orders and participate in the wound management/evaluations. They can write orders in all settings in which they receive Medicare payments (assuming their state licensure allows them to do so.) See CMS IOM Publication 100-4, Chapter 12, Section 120 for more information.
Where can I find the list of covered conditions?
The list can be found in the CMS Internet Only Manual (IOM) 100-03, Chapter 1, Part 1, Section 20.29, Hyperbaric Oxygen Therapy.
How do I support the need for HBO therapy?
HBO Therapy is covered as adjunctive therapy only. The documentation needs to clearly and legibly support that the treatment is one of the covered conditions approved by CMS. The documentation will need to support the onset of the condition, diagnostic reports, wound measurements and any prior medical/surgical treatment provided.
- History and physical
- Signed order
- Procedure logs including ascent and decent times, with pressurization level
- Treatment record with wound progress
- Surgical, antibiotic treatment, x-rays, lab results, and failed medical treatment
- Adjunctive treatment(s)
- HBO treatment record to showing progress of the wound and/or specific condition