The Jurisdiction E, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of for Healthcare Common Procedure Coding System (HCPCS) G0277 - Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval. The quarterly edit effectiveness results from October 1, 2022 through December 31, 2022 are as follows:

Top Denial Reasons

• Insufficient Documentation
• Coverage and Medical Necessity of Hyperbaric Oxygen Therapy
• HBO Therapy for Soft Tissue Radionecrosis

Educational Resources

• Documentation Requirements
• Hyperbaric Oxygen (HBO) Therapy Resources
• National Coverage Determination (NCD): Hyperbaric Oxygen Therapy (20.29)

Education

Coverage and Medical Necessity of Hyperbaric Oxygen Therapy

National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29) details the indications and limitations of coverage for Hyperbaric Oxygen Therapy (HBO) services. Medicare coverage of HBO is limited to the indications specified. Documentation should clearly support the patient is receiving HBO services for a covered indication. This includes the patient’s diagnosis and all supporting documentation regarding the patient's diagnosis/condition to support a covered indication per the NCD.

HBO Therapy for Soft Tissue Radionecrosis

Soft tissue radionecrosis (STRN) is a covered indication for HBO therapy as an adjunct to conventional treatment. Conventional treatment may include debridement or resection of non-viable tissues, antibiotics, and tissue reconstruction or grafting as indicated. STRN involves subsequent deterioration of skin or bladder tissue after radiation treatment of cancer. Damaged tissue would be expected to heal were it not for the previous radiation injury to the cancer site and adjacent tissue. Documentation supporting HBO treatment for STRN includes, but is not limited to:

• Date and site of prior radiation treatment(s)
• Any prior and concurrent medical treatments, surgical interventions, and debridement of non-viable tissue
• Prior HBO treatments, if applicable
• Laboratory reports
  • Microorganism cultures guiding antibiotic therapy
  • Diagnostic testing to support presence of STRN, for example:
    • Cystoscopy
    • Biopsy
    • Other causes, for example cancer or ischemia, should be ruled out

Physician consultations, procedure reports, and treatment recommendations.

Diabetic Wounds

NCD 20.29 details coverage of diabetic wounds of the lower extremities. Documentation must support a type I or type II diabetic beneficiary with a wound classified as Wagner grade 3 or higher that has failed an adequate course of standard wound therapy.
Per the Decision Memo for Hyperbaric Oxygen Therapy, which can be located as a link on the NCD under National Coverage Analyses “Original Consideration for Hyperbaric Oxygen Therapy for Hypoxic Wounds and Diabetic Wounds of the Lower Extremities;” a Wagner grade 3 wound is a lesion that has penetrated deeper than a grade 2 and there is abscess, osteomyelitis, pyarthrosis, plantar space abscess, or infection of the tendon and tendon sheaths. Wagner grade 4 and 5 involve gangrene to the toes, forefoot, or whole foot.

Billing Hyperbaric Oxygen Therapy Units

HCPCS G0277 description is per 30 minutes. Additional units may be billed for sessions requiring at least 16 minutes of the next 30 minute intervals. Medical review noted claims in which the documentation supporting the Hyperbaric Oxygen Therapy (HBO) treatment time did not support the units billed.

HBO sessions with a duration of:

• 46 - 75 minutes should be billed with 2 units of G0277
• 76 - 105 minutes should be billed with 3 units of G0277
• 106 - 135 minutes should be billed with 4 units of G0277