I received an email from a physician who expressed how difficult it was to stay updated on the requirements for HBOT documentation. Dr. Helen Gelly has written about this extensively and I have posted blogs about this before. I reviewed the HBOT documentation requirements at the Fall SAWC last week.
It’s helpful to remember how we got here. I was UHMS President in 1998 when the OIG reviewed HBOT claims between 1995-1998 and determined the following:

  • 9.2% of HBOT claims were inappropriately paid due to inadequate documentation
  • 11% HBOT claims were for excessive  treatments
  • 22.4% HBOT claims were paid for non-covered indications
  • 74% HBOT claims were performed without a physician in attendance

YES! You heard that correctly. The OIG determined that 1998, 74% of the time, when HBOT was billed, the doctor was not present. It may be useful to think about this OIG report when you read the HBOT documentation requirements listed below. The most important reminder I can give you is to read your Medicare Administrative Carrier (MAC’s) local coverage policy on HBOT, and any FAQs that have been posted. Sign up for your MACs list serves so that you are notified of any alerts or changes. The rest of us are not psychic – we are on a lot of list serves. It means we spend a lot of time slogging through emails each day, but it limits the likelihood we will miss something, and the more people watching, the better.
Medicare Advantage has expanded its Prior Authorization and are requiring that practitioners document what you should be doing for hyperbaric chamber supervision, requiring the following:

  • Documentation that the patient is cleared for HBOT that day
  • The physician orders HBOT daily after an assessment
  • There is general forward progress
  • Remind patient no smoking, eat more protein, take supplements
  • The physician should document they were physically present  during the treatment and immediately available (and the technician must do the same)

HBOT Prior Authorization was demanding for DFU’s requiring all of the following documentation (which are included in Medicare coverage policy):

  • Evidence of glycemic control
  • Optimization of nutritional status
  • Debridement of devitalized tissue
    • Granulation bed that is present but wound still not getting smaller based on measurements which are performed at each visit
  • Resolution of infection
  • Evidence of vascular assessment and optimization insofar as possible
    • Palpable pulse were NOT good enough (any non-invasive testing was accepted)
  • OFFLOADING documented every time, every visit for 4 weeks

Here is a list of Reasons for Denial of HBOT payment that comes directly from the MAC:

  • Physician must order HBOT each day
  • Physician must order blood sugars if they are performed
  • Make sure that the HBO note has the correct indications for treatment in the note
  • The Physician must order the hyperbaric oxygen therapy and specify: Depth, Duration, Air breaks, Blood sugars, Expected number of treatments and segments and frequency (i.e. Monday-Friday or BID etc.)
  • You must define specific goals of treatment for each HBOT indication.
  • You must define how you are going to overcome obstacles to healing.
  • Documentation must support there is an improvement with HBO services and reasonable to continue treatment
  • Re-assessment of wound every 30 days including wound measurements
  • You will need HBOT goals for each HBOT indication
  • Radiation patients: document radiation treatment, cancer type and location, and lack of response to conventional care
  • State that the patient was treated in a “hard-sided chamber”
  • State that the patient was treated with 100% oxygen
  • The physician must state that they were physically present for the treatment and the hyperbaric technician should confirm that the physician was present.
  • Some MAC’s require that the physician document that they are ACLS certified

Novitas “Targeted Probe and Educate” (TPE) for HBOT Results: Through complex data analysis Medical Review Part A identified provider billing practices and services that pose the greatest financial risk to the Medicare program.

  • Providers chosen to participate in HBO Targeted Probe & Educate (TPE) were offered education prior to, during, and after the probe process had been completed
    • 12 probes completed
    • 7 minor errors
    • 1 moderate error
    • 3 major errors
    • 1 insufficient sample size

The most common reasons for denial of HBOT claims under the Novitas TPE were:

  • Insufficient documentation to support services medically reasonable and necessary
  • Incomplete or missing treatment records
  • Insufficient documentation of diagnostic or physician progress note to confirm diagnosis
  • Insufficient documentation of response to treatment or measurable signs of healing
  • Insufficient documentation of failed standard treatment or debridement of diabetic wounds
  • Missing signed physician’s order for treatment