Hyperbaric Oxygen (HBO) Therapy Targeted Probe and Educate Review Results

The Jurisdiction F, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of Healthcare Common Procedure Coding System (HCPCS) G0277 – Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows:

Top Denial Reasons

  • Documentation does not support coverage and medical necessity requirements per NCD.

Educational Resources

Education

Coverage and Medical Necessity of Hyperbaric Oxygen Therapy

The 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 also all supporting documentation regarding the patient's diagnosis/condition to support a covered indication per the NCD.

Wagner Grade 3 Diabetic Wounds

The NCD for Hyperbaric Oxygen Therapy (20.29) details coverage of diabetic wounds of the lower extremities in patients who meet specific criteria: Diabetic patients with a wound classified as Wagner grade 3 or higher; and 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.

Coverage and Medical Necessity of Hyperbaric Oxygen Therapy

The 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 also all supporting documentation regarding the patient's diagnosis/condition to support a covered indication per the NCD.

 

Last Updated Thu, 21 May 2020 20:55:09 +0000