Hyperbaric Oxygen (HBO) Therapy Services Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check Brief Description
 

Legible handwritten physician and/or clinician signatures

 

Valid electronic physician and/or clinician signatures

 

Physician or Non-Physician Practitioner (NPP) order for date of service, if applicable

  • Supporting how many HBO treatments are ordered
 

Initial HBO evaluation/consultation by the physician or NPP

 

Documentation supporting HBO covered condition(s) for National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29)

This is not an all-inclusive list

  • For treatment of soft tissue radionecrosis and osteoradionecrosis-documentation of history of radiation therapy including date and site of radiation and conventional treatment the patient is receiving adjunctive to HBO
  • For treatment of compromised skin graft-documentation supporting when graft occurred
  • For chronic refractory osteomyelitis-radiographic evidence and/or bone cultures confirming a definitive diagnosis of osteomyelitis, documentation of conventional medical management to which patient did not respond and documentation of conventional surgical management to which patient did not respond
 

Progress notes

  • HBO clinic/progress notes
  • Clinic/hospital/progress notes prior to starting HBO, if applicable
  • Support of the initial wound/condition etiology
  • Support of prior history of treatment for the condition/wound(s), if applicable
 

HBO Treatment plan

  • Atmospheric pressures
  • Rest/Air breaks
  • Frequency and number of dives
  • Blood glucose monitoring, if applicable
  • Wound assessments, if applicable
  • Evaluation of progress
 

HBO dive logs/treatment records

  • Documentation should include minutes completed during HBO treatment
  • Documentation should support when blood glucose measurements are taken and the results, if applicable
 

Wound treatment records or wound flow sheets supporting measurable signs of healing

  • Wound measurements, if applicable
  • Subjective findings regarding wound, if applicable
 

Diabetic wound(s) required documentation:

  • Wagner grade classification (must be Wagner grade III of higher) with diagnostic testing to support Wagner grade;
  • Patient has type 1 or type 2 diabetes and has lower extremity wound due to diabetes;
  • Documentation supporting prior failed treatment using standard wound care;
  • Documentation supporting there were no measureable signs of healing for at least 30 consecutive days of treatment when using standard wound therapy;
  • Evaluation of wound at least every 30 days during administration of HBO therapy that supports evidence of measurable signs of healing  
 

Standard diabetic wound care therapy documentation required prior to starting HBO:

  • Assessment of patient's vascular status and correction of problems, if applicable
  • Support of optimization of nutritional status
  • Support of optimization of glucose control
  • Support of debridement of the devitalized tissue
  • Support of the wound care management that includes maintenance of a clean, moist bed of granulated tissue with appropriate moist dressing
  • Support of appropriate off-loading
  • Support of treatment to resolve infection
 

Evaluation and Management (E&M) documentation, if billed on same date of service under medical review

 

Itemization of services

 

Advance Beneficiary Notice of Noncoverage (ABN), if applicable


Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Outpatient Prospective Payment System (OPPS) webpage for additional information and resources.

Last Updated Feb 08, 2019

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.