CMS Reasons for Denial of Hyperbaric Oxygen Therapy - Check Out What's Required in Your Medical Record

This is part of my series of articles about Useful Information on Medicare Audits.

Here are the “reasons for denial” codes for hyperbaric oxygen therapy posted on the Palmetto website. Although they are posted on the Palmetto website, these come from CMS and thus are universal for all MACs. What is scary here is that a lot of this is open to interpretation by the auditor such as: documentation indicating patient was unresponsive to conventional medical and surgical management, documentation patient has failed an adequate course of standard wound therapy, documentation addressing the patient’s nutritional status, optimal glucose control, or no documentation that treatment is an adjunct to conventional therapy.

Take special note of this: Hyperbaric Oxygen (HBO) therapy treatment records did not include the ascent time, descent time, total compression time, dose of oxygen, pressurization level, documentation of attendance, and a recording of events.

There are a lot of implications here when it comes to documentation…


Palmetto GBA Full Denial Code	Palmetto GBA Partial Denial Code	Palmetto GBA Granular Denial Reason	Palmetto Denial Description	CMS Reason Code	CMS Statement
5D169	5H169	The medical records submitted do not match the beneficiary billed on the Hyperbaric Oxygen (HBO) therapy claim (HBO6E).	Services Not Documented.	HBO6E	The medical records submitted do not match the beneficiary billed on the Hyperbaric Oxygen (HBO) therapy claim.
5D169	5H169	Date(s) of service on the documentation do not match the date(s) of service billed on the claim for Hyperbaric Oxygen Therapy, (HBO6A).	Services Not Documented.	HBO6A	Date(s) of service on the documentation do not match the date(s) of service billed on the claim for Hyperbaric Oxygen Therapy.
5D164	5H164	Documentation does not include history and physical along with any previous treatment (i.e. antibiotic therapy, surgical interventions) for specified condition, (HBO1A).	Doc submitted does not support med nec (provider liable).	HBO1A	Documentation does not include history and physical along with any previous treatment (i.e. antibiotic therapy, surgical interventions) for specified condition.
5D164	5H164	Progress updates with response to treatment and measurable signs of healing not provided, (HBO1F).	Doc submitted does not support med nec (provider liable).	HBO1F	Progress updates with response to treatment and measurable signs of healing not provided.
5D164	5H164	The documentation does not include a covered diagnosis per the NCD, (HBO1B).	Doc submitted does not support med nec (provider liable).	HBO1B	The documentation does not include a covered diagnosis per the NCD.
5D920	5H920	There is no documentation that patient has chronic refractory osteomyelitis, (HBO2L).	The recommended protocol was not ordered and/or followed.	HBO2L	There is no documentation that patient has chronic refractory osteomyelitis.
5D920	5H920	Documentation of diagnostic test and/or labs not provided to support specified condition, (HBO1I).	The recommended protocol was not ordered and/or followed.	HBO1I	Documentation of diagnostic test and/or labs not provided to support specified condition.
5D920	5H920	There is no documentation indicating patient was unresponsive to conventional medical and surgical management for chronic refractory osteomyelitis, (HBO2M).	The recommended protocol was not ordered and/or followed.	HBO2M	There is no documentation indicating patient was unresponsive to conventional medical and surgical management for chronic refractory osteomyelitis.
5D920	5H920	There is no documentation patient has both type I or type II diabetes and a lower extremity wound that is due to diabetes, (HBO2U).	The recommended protocol was not ordered and/or followed.	HBO2U	There is no documentation patient has both type I or type II diabetes and a lower extremity wound that is due to diabetes.
5D920	5H920	There is no documentation patient has failed an adequate course of standard wound therapy for diabetic wound management, (HBO2W).	The recommended protocol was not ordered and/or followed.	HBO2W	There is no documentation patient has failed an adequate course of standard wound therapy for diabetic wound management.
5D920	5H920	There is no documentation patient has a diabetic wound classified as Wagner grade III or higher, (HBO2V).	The recommended protocol was not ordered and/or followed.	HBO2V	There is no documentation patient has a diabetic wound classified as Wagner grade III or higher.
5D920	5H920	There is no documentation addressing the patient's nutritional status for diabetic wound management, (HBO2Y).	The recommended protocol was not ordered and/or followed.	HBO2Y	There is no documentation addressing the patient's nutritional status for diabetic wound management.
5D920	5H920	There is no documentation indicating the patient's vascular status was addressed for diabetic wound management, (HB2AB).	The recommended protocol was not ordered and/or followed.	HB2AB	There is no documentation indicating the patient's vascular status was addressed for diabetic wound management.
5D920	5H920	There is no documentation indicating optimal glucose control for diabetic wound management, (HB2AC).	The recommended protocol was not ordered and/or followed.	HB2AC	There is no documentation indicating optimal glucose control for diabetic wound management.
5D920	5H920	There is no documentation indicating that the appropriate off-loading measures have been utilized for diabetic wound management, (HB2AD).	The recommended protocol was not ordered and/or followed.	HB2AD	There is no documentation indicating that the appropriate off-loading measures have been utilized for diabetic wound management.
5D920	5H920	There is no documentation showing measurable signs of improvement of the diabetic wound after 30 days of Hyperbaric Oxygen (HBO) therapy, (HB2AG).	The recommended protocol was not ordered and/or followed.	HB2AG	There is no documentation showing measurable signs of improvement of the diabetic wound after 30 days of Hyperbaric Oxygen (HBO) therapy.
5D920	5H920	HBO2N: There is no documentation that patient has Osteoradionecrosis, (HBO2N).	The recommended protocol was not ordered and/or followed.	HBO2V	There is no documentation patient has a diabetic wound classified as Wagner grade III or higher.
5D920	5H920	There is no documentation that treatment is an adjunct to conventional treatment for osteoradionecrosis, (HBO2O).	The recommended protocol was not ordered and/or followed.	HBO2Y	There is no documentation addressing the patient's nutritional status for diabetic wound management.
5D920	5H920	There is no documentation that patient has soft tissue Radionecrosis, (HBO2P).	The recommended protocol was not ordered and/or followed.	HB2AB	There is no documentation indicating the patient's vascular status was addressed for diabetic wound management.
5D920	5H920	There is no documentation that treatment is an adjunct to conventional treatment for soft tissue Radionecrosis, (HBO2Q).	The recommended protocol was not ordered and/or followed.	HB2AC	There is no documentation indicating optimal glucose control for diabetic wound management.
5D920	5H920	There is no documentation that patient needs preparation and/or preservation of compromised skin grafts, (HBO2K).	The recommended protocol was not ordered and/or followed.	HB2AD	There is no documentation indicating that the appropriate off-loading measures have been utilized for diabetic wound management.
5D920	5H920	There is no documentation that patient has acute traumatic peripheral ischemia, (HBO2E).	The recommended protocol was not ordered and/or followed.	HB2AG	There is no documentation showing measurable signs of improvement of the diabetic wound after 30 days of Hyperbaric Oxygen (HBO) therapy.
5D920	5H920	There is no documentation that adjunctive treatment was used in combination with accepted standard therapeutic measures when loss of function, limb or life is threatened for acute traumatic peripheral ischemia, (HBO2F).	The recommended protocol was not ordered and/or followed.	HBO2F	There is no documentation that adjunctive treatment was used in combination with accepted standard therapeutic measures when loss of function, limb or life is threatened for acute traumatic peripheral ischemia.
5D920	5H920	There is no documentation of crush injuries and suturing of severed limbs, (HBO2G).	The recommended protocol was not ordered and/or followed.	HBO2G	There is no documentation of crush injuries and suturing of severed limbs.
5D920	5H920	There is no documentation of adjunctive treatment when loss of function, limb, or life is threatened for crush injuries and suturing of severed limbs, (HBO2H).	The recommended protocol was not ordered and/or followed.	HBO2H	There is no documentation of adjunctive treatment when loss of function, limb, or life is threatened for crush injuries and suturing of severed limbs.
5D920	5H920	There is no documentation that patient has acute peripheral arterial insufficiency, (HBO2J).	The recommended protocol was not ordered and/or followed.	HBO2J	There is no documentation that patient has acute peripheral arterial insufficiency.
5D920	5H920	No documentation to support that patient has acute peripheral arterial insufficiency, (HBO2J).	The recommended protocol was not ordered and/or followed.	HBO2J	There is no documentation that patient has acute peripheral arterial insufficiency.
5D920	5H920	There is no documentation that treatment is an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment for Actinomycosis, (HBO2T).	The recommended protocol was not ordered and/or followed.	HBO2T	There is no documentation that treatment is an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment for actinomycosis.
5D169	5H169	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, (HBO1C).	Services Not Documented.	HBO1C	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.
5D169	5H169	Documentation does not indicate the entire body was exposed to oxygen under increased atmospheric pressure, (HBO1G).	Services Not Documented.	HBO1G	Documentation does not indicate the entire body was exposed to oxygen under increased atmospheric pressure.
5D151	5H151	Number of units billed does not match treatment log, (HBO6G).	Units Billed More Than Ordered.	HBO6G	Number of units billed does not match treatment log.
5D199	5H199	All or part of the claim was billed in error by the provider.	Billing Error.	GAK09	Documentation does not support the claim as billed. Refer to Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 100-04 Medicare Claims Processing Manual, Chapter 23.
5DMDP	5HMDP	Dependent, qualifying services medically denied	Dependent, qualifying srvc medically denied.	GAJ02	Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15.
5DTDP	5HTDP	Dependent, qualifying services technically denied.	Dependent, qualifying srvc technically denied	GAJ02	Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15.

Caroline Fife, M.D.

Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos

The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.

CMS Reasons for Denial of Hyperbaric Oxygen Therapy – Check Out What’s Required in Your Medical Record

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