Yesterday a friend who practices hyperbaric medicine called me about a reimbursement question because she had just read the Novitas LCD on the subject. I told her that the Novitas LCD was the least of our problems.  HBOT utilization is down 50% across the USA. Listed below are 10 reasons why this has occurred, and why the use of HBOT, even for patients who need it and meet the criteria for it, is likely to decrease even further:

  1. Audits of HBOT by every payer, at every point in the claim cycle
    • Private payers (including Medicare “Advantage”) have implemented prior-authorization of HBOT.  In many cases, they have decided not to cover long accepted HBOT indications.
    • Nearly all Medicare Administrative Carriers (MACs) have implemented pre-payment review. In some cases, this process includes mandating that patients with radionecrosis also have a diabetic foot ulcer, due to an apparently unfixable error in the guidance document for reviewers.
    • Many MACs have now begun Targeted Probes (see blog post below).
  1. Just Say “no”- Private payers simply deciding not to cover indications previously covered
    • This is the real threat to HBOT coverage.
    • In the near future, the majority of Medicare patients will be enrolled in Medicare Advantage plans and these payers are clearly not implementing Medicare policy.
    • Private payers can do whatever they like. They are not subject to the oversight of Congress.
  2. ICD-10 resulting in “uncovered” indications due 
    • The implementation of ICD-10 had the effect of denying coverage for some indications because the “cross walk” for some ICD-9 codes took coverage down one pathway at the exclusion of others (e.g. coverage for failing skin grafts but not for failing flaps).
  3. Designating some HBOT indications as “in-patient only”
    • Novitas has done this for gas gangrene, sequalae of acute peripheral ischemia (including reperfusion conditions of arterial embolism and thrombosis, reimplantation or crush injuries of the extremities), necrotizing fasciitis, air embolisms, carbon monoxide/cyanide poisoning.
    • It’s a brilliant approach. The MACs cannot say they have limited coverage but they are well aware that the “outpatient only” approach to HBOT by most centers will prevent patients from being treated for these indications.
  4. Changing Physician incentives away from volume based payment via the Merit Based Incentive Payment System (MIPS)
    • Medicare Spending Per Beneficiary (MSPB) and HBOT:
      • HBOT is expensive. Patients who need it rack up a lot of Medicare charges.
      • Those charges are accrued to the MSPB calculation of each supervising physician.
      • If Medicare’s calculations for the patients’ relative level of sickness do not indicate that the physician’s average MSPB is reasonable, the hyperbaric will be viewed as “overspending” the Medicare budget.
      • We must begin to represent how sick our patients are and how poor the outcome of many may be, in order to create the value proposition for HBOT.
      • This is the reason you had better ensure that your EHR can capture the Hierarchical Classification Codes associated with each HBOT patient (see links below).
    • Quality Measures and HBOT:
      • Quality Measures comprise 50% of MIPS in 2018.The USWR developed hyperbaric specific quality measures in conjunction with the UHMS that can be reported for MIPS credit
      • Reporting hyperbaric quality measures can raise the quality score of HBOT practitioners and thus improve the overall MIPS score, protecting physician revenue and even helping practitioner achieve bonus payments
      • This could be the difference between surviving and not surviving a switch of HBOT to the office based setting.
      • We need more HBOT quality measures. The UHMS funded 6 originally, but CMS rejected 4 of them after 2 years due to lack of reporting (among other issues). We need more, but the funding does not exist, and there is no reason to fund more measures if no one intends to report them.
      • Word to the wise, if you don’t intend to report hyperbaric relevant quality measures, that may mean you don’t intend to practice hyperbaric medicine for very much longer.
  5. MAC Coverage Policies for HBOT that are internally inconsistent and not evidence-based
    • As only one example, the Novitas policy requires that DFUs have no evidence of improvement over 4 weeks. However, it also requires debridement of necrotic material and the presence of granulation tissue to justify HBOT, which, by definition, is an improvement in the wound. It is simply not possible for a DFU to improve and not improve at the same time. The policy also requires the control of infection in Wagner 3 DFUs, even though infection is part of the definition of a Wagner 3 ulcer.
  6. Fraud investigations by the HEAT based on patterns of national claims data
    • The Health Care Fraud Prevention and Enforcement Action Team (HEAT) is an unprecedented joint initiative between Health and Human Services (that oversees CMS), the Office of Inspector General (OIG), and the Department of Justice (DOJ). Money returned to Medicare ($31 billion so far) is currently a primary sources of Medicare funding.
    • Analysis teams examine Medicare claims for known fraud patterns and calculates the ratio of allowed services compared to national averages.
    • This is one of the primary reasons to engage in national benchmarking through the HBOTR because it will shed light on any billing practices that may be, even inadvertently outside the norm.
    • Fraud investigations are also the most compelling reason for practitioners and facilities to voluntarily report quality measures.
  7. The possible loss of HBOT Facility Fees through a “site neutral” payment adjustment
    • Congress is under intense pressure to save Medicare dollars. Many services currently offered in hospital outpatient departments are undergoing payment adjustments the result of which is to move them into the doctor’s office. (See Dr. Gelly’s article about this below). It could happen.
      • It should be noted that the failure of many hospital based outpatient facilities to follow Medicare rules for physician supervision (i.e. a physician must be physically present for any services to be delivered) is one reason that the OIG recently recommended that CMS completely disband the hospital based outpatient payment system.
      • The majority of hyperbaric centers currently look and act like doctor’s offices because they are located in office buildings disconnected from the hospital, they do not treat hospital in-patients, and they have no emergency hyperbaric “call.”
    • IF a site of service adjustment were to happen, it would mean all HBOT services would have to be delivered in the physician office setting.
    • That is one of the reasons that the UHMS QUARC committee has paid so much attention to threats affecting physician payment for HBOT services.
    • Since the future of hyperbaric medicine could depend on physician payment, this further magnifies the issues pertaining to MIPS.
  8. A threatened reduction in the payment rate for the Physician Supervision of hyperbaric treatment
    • A substantial reduction in payment would likely have been recommended by the AMA-RUC committee, but was avoided because of the dedicated work of Helen Gelly and the data provided by the Hyperbaric Oxygen Therapy Registry (HBOTR), sponsored by the US Wound Registry (USWR).
  9. Detailed documentation requirements by the MACs which will require significant collaboration and support from your EHR vendor. For example
    • To provide HBOT for a DFU, the following documentation is required:
      • Evidence of glycemic control, specifically an A1C recorded in the chart, and different MACs are requiring different A1C levels*
      • Optimization of nutritional status (not defined in the policy) *
      • Debridement of devitalized tissue
      • A granulating wound bed that is present (but not actually improving because that would indicate improvement in the wound which would negate the need for HBOT)
      • Wound Measurements done at every visit which do not show that the wound is smaller
      • Resolution of any infection
      • Evidence of vascular assessment* (palpable pulse are NOT good enough- you need the report of an arterial assessment of some sort such as Arterial Doppler, TCOMs, skin perfusion pressure)
      • Clear evidence that the wound is a Wagner 3 (this is hard since you need bone or joint exposure to satisfy this but the infection needs to be treated except that you have to have infection to have a Wagner 3)
      • An order for the hyperbaric oxygen treatment every day
      • An order for blood sugar to be checked every day in the case of a diabetic patient undergoing HBOT*
      • Treatment goals for HBOT (this is true for all HBOT indications)
      • A plan of care discussing how you will overcome obstacles to the goals of treatment (true for all indications)

* Indicates an activity that is also a Quality Measure through the US Wound Registry.

  • Reasons for Denial of payment for HBOT treatments (not inclusive):
    • The HBOT note did not say that the patient was treated in a “hard sided” chamber
    • The HBOT note did not say that the entire body was exposed to oxygen
    • Hyperbaric Oxygen (HBO) therapy treatment records not provided or did not include the ascent time, descent time, total compression time, dose of oxygen, pressurization level, documentation of attendance, and a recording of events.
    • The documentation did not include the diagnostic test that was referenced in the physician narrative to confirm diagnosis
    • The documentation showed that there were “measurable signs of improvement” to the wound with the use of standard wound care prior to the initiation of Hyperbaric Oxygen (HBO) therapy
    • Some insurance plans are requiring the doctor to have ACLS and state this in the HBOT note
    • For Radiation patients: you must document radiation dose, type of cancer, and lack of response to conventional care
    • An order for HBOT which must include:
      • Treatment Depth
      • Treatment Duration
      • Air breaks
      • Blood sugars if applicable
      • Expected number of HBOT treatments
      • Number of HBOT SEGMENTS

Eighteen years ago, I warned everyone that this could be our future in an editorial in “Pressure” magazine at the end of my tenure as President of the Undersea and Hyperbaric Medical Society (UHMS). That’s not because I’m psychic. It’s because the Coverage Policy staff at CMS told me they would do this if we didn’t police ourselves. It’s fair to say that improper and overuse of HBOT (and the payers’ response to it) has brought us to this.
I personally think that only way to save Hyperbaric Medicine is through registry reporting and national benchmarking, which is how other medical specialties behave. I’ve taken a lot of heat for this but I don’t care. If you took the time to read what I listed above, you understand why.
In the meantime, for those hyperbaric medicine practitioners who have not noticed that the Hyperbaric ship is riding very low in the water and that many of your colleagues have on lifejackets, I’ve organized below some of the many blog posts, on-line resources and open-source peer reviewed articles to make it easier for you to catch up. Helen Gelly and I have been writing about this as fast as we could for more than 4 years, so I hope this is a review.

A word of Thanks to the Clinicians and the Companies who are bailing water out of the boat

We have survived this far thanks to the tireless work of Helen Gelly. She and I are both grateful to Marc Robins who is the organizing, and steading force of the excruciatingly named UHMS Quality, Utilization, Authorization, and Reimbursement Committee (QUARC).
I want to thank the following companies that support the USWR through registry reporting from their managed facilities: Precision Healthcare, HyperbaricRx, Serena Group, Cutis Care, Holmes Healthcare, Lifepoint Health, and Outpatient Integrated Strategies. Thank you for being committed to Doing the Right Thing.
There are about 134 facilities in total, and just shy of 600 practitioners who want to Do The Right ThingTM through quality reporting, with nearly 2000 practitioners coming on board with basic benchmarking. The USWR/HBOTR has no ongoing source of funding, except for your participation.
Here’s what the rest of you need to do now:

  1. Join the UHMS AND the American College of Hyperbaric Medicine
    • Both organizations are working actively
    • Follow the “members only” reimbursement information posted by the QUARC committee.
  2. Call the US Wound Registry (USWR).
    • (281) 771-DOCS (3627): Available Monday – Friday, 7:30AM to 5:30PM Central Standard Time
    • Talk to a representative about how you can participate in quality reporting or benchmarking.
  3. Donate money to the USWR. It’s a 501(c)(3) non-profit. It doesn’t go to me.
    • Our next project is a “Physician Compare” type site where practitioners can report quality data even if they are not formally reporting it to CMS as part of MIPS.
  4. Get your own facility ready
    • Call medical records and whoever is in charge of revenue integrity- find out whether they are already handling audits of HBOT patients. Get involved in those audits.
    • If you have any denials, redact the PHI and contact Helen Gelly or me so that we can add this information to our repository and let others learn from your experience.
    • Go to the UHMS meeting where you can learn more about what is happening
  5. Keep up –
    • Attend the UHMS annual meeting or one of the chapter meetings if you can
    • Read your MAC LCD, Today’s Wound Clinic, this blog, the UHMS QUARC materials, UHMS “Pressure”, your county medical society, and anything else you can

This is not a drill. The lifeboats are loading.
Here’s some reading material to keep you company: