Recently, a clinician inquired about Medicare documentation requirements for hyperbaric oxygen therapy (HBOT). In particular, they wanted to know once a patient has started HBOT, how often the follow up visits with the physician should be performed, and what should be documented in that visit? Are chart reviews sufficient to determine continuation of treatment or are face to face follow ups required?

Those questions raise a lot of other questions. If HBOT is being provided in the office-based setting, the physician must be physically present for the HBOT to determine the suitability for each day’s treatment and to supervise the patient throughout the treatment. In the hospital based outpatient department, HBOT is still provided “incident to” the physician visit, but Medicare now allows hospitals to decide whether physicians supervision will be “direct” (meaning the doctor is physically present) or “general” (meaning the doctor is supervising remotely). The problem with remote supervision of HBOT is that if anything goes wrong, the physician is still medicolegally liable for the care of the patient – even if they are not there.

The frequency of HBOT followup visits is determined by the diagnosis being treated. The minimum requirement for some indications is a follow up visit within 30 days (e.g., for a diabetic foot ulcer). However, some indications state that HBOT should be stopped if there is no evidence of progress within the 30-day window. For something like a failed flap, progress would need to be determined on a daily basis (although that’s not specifically stated in a policy) — since it’s expected that we will tailor the treatment regimen to the response.

The physician asked if a “chart review” would be sufficient to determine progress. Most HBOT treatment notes do not include a progress evaluation,  so the patient would need to be seen specifically to assess their progress. A typical approach is to have a progress visit every 10 treatments. That visit is separate and distinct from the hyperbaric procedure note, because you are addressing the issue of potentially changing the protocol. Most Medicare Administrative Carriers (MACs) require that HBOT (and other advanced therapeutics) be given as part of a comprehensive Plan of Care which includes measurable goals of therapy. That means you must identify a specific goal for every hyperbaric indication (e.g., for a DFU you might have a goal of “increased granulation tissue”). The goals must be measurable- so don’t make “improved tissue oxygenation” a goal unless you plan to measure tissue oxygenation. When you document that HBOT follow-up visit, you will be documenting how much progress has been made on the specific goals you identified when you initiated HBOT. In some cases, that means getting detailed information about symptoms like hematuria if the patient is being treated for late effects of radiation. In my opinion, the requirement is a face-to-face to determine the progress made on the goals you already identified.

Keep in mind that if audited, you will need to provide a lot more than the HBOT treatment note for any given day. Depending on what treatments are audited, you might need to provide that interval follow up assessment to justify the additional treatments provided, the Plan of Care, and documentation of the treatments that failed prior to starting HBOT. Medicare tells you what you have to provide as a baseline for hyperbaric documentation. Every practitioner should review the HBOT documentation requirements of their MAC.  The person who asked the question is in the Noridian jurisdiction and you can find the Noridian requirements here. Every hyperbaric physician should be intimately familiar with the HBOT documentation requirements of their MAC.

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Clinician Checklists Hyperbaric Oxygen (HBO) Therapy.pdf noridian