Hyperbaric Oxygen (HBO) Therapy - JF Service Specific Post-Payment Final Findings - JF Part A
Hyperbaric Oxygen (HBO) Therapy - JF Service Specific Post-Payment Final Findings
CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Noridian’s priority is to minimize potential future losses to the Medicare Trust Fund by preventing inappropriate Medicare payments. This is accomplished through provider education, training, and the medical review of claims. A post-payment review has been initiated based on data analysis.
This is to update providers of the claim review findings and closure of the file of Healthcare Common Procedure Coding System (HCPCS) code G0277 for Jurisdiction F.
Summary of Findings
Since the initiation of the review, 100 claims were reviewed from January 18, 2021 through August 26, 2021 with an overall claim error rate of 69% and payment error rate of 77.2%. The breakdown of those findings are as follows:
- 31 claims were accepted
- 1 claim were partially denied for the following reason:
- Documentation did not support number of units billed
- 68 claims were denied in full for the following reasons:
- Documentation did not support medical necessity per NCD requirements
- Documentation did not support a covered diagnosis
- Documentation did not support previous treatment tried
- Documentation was not received timely in response to the additional documentation request (ADR)
- Documentation did not support dive records
If you are a provider that had claims involved in the review sample and disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice.
Education
| Paragraph Name | Paragraph Details |
|---|---|
| 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. 2 units G0277 should be billed for HBO session duration between 46 and 75 minutes 3 units G0277 should be billed for HBO session duration between 76 and 105 minutes 4 units G0277 should be billed for HBO session duration between 106 and 135 minutes |
| 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 also all supporting documentation regarding the patient’s diagnosis/condition to support a covered indication per the NCD. |
| Wagner Grade 3 Diabetic Wounds | The National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (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. |
| Documentation Supporting Services Rendered | Under section 1833(e), Title XVIII of the Social Security Act (SSA) states, "no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period." No Medicare payment can be paid for claims that lack the necessary information for processing. Medicare claims will be allowed to process, when there is sufficient documentation in the patient’s records to verify the services were performed and were medically necessary and reasonable for the medical condition. Justification for the service may be documented in the physician’s clinic or hospital progress notes and/or laboratory results. If there is no documentation, or insufficient documentation to support the service, then Medicare considers the service was not rendered. Services will be denied without the necessary documentation to support services were rendered as billed. |
| Medical Necessity | As laid out in section 1862(a)(1)(A) of Title XVIII of the Social Security Act, no Medicare payment may be made for items or services that are not reasonable and necessary for diagnosis or treatment of illness/injury or to improve the function of a malformed body part. Medical necessity is a term used when determining whether a diagnosis or treatment by a physician is considered appropriate or inappropriate, based on medical standards of care. Medicare can only allow services that meet this standard. To be considered medically necessary, items and services must be proven as safe and effective. Medicare is aware that some patients do and will require professional services at a greater frequency and duration than others, including more extensive diagnostic procedures. Documentation verifying medical necessity for such treatment must be recorded in the medical records. Documentation that the services were rendered is necessary for a claim to be properly evaluated. |
| Reasonable and Necessary | Per the Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual (MPIM), Chapter 3, Section 3.6.2.2, for services with no National Coverage Determination (NCD) or Local Coverage Determination (LCD), Medicare contractors must determine whether services are reasonable and necessary. To determine if a service is reasonable and necessary contractors consider the following information:
|
View references used in review. Further educational opportunities may be found under Education and Outreach. If you are in need of an individualized education training event, contact the POE Department at mac@noridian.com. If you need coding assistance, please check your CPT®, HCPCS, ICD-10 books and your specific association.
Provider Action Required
File results and trending errors are being shared with all providers to assess compliance and billing practices if the service is provided within your facility. If your facility had claim documentation requested for this review, please refer to the individual result letter you received. You can also access individual determinations for claims that were requested from your facility by reviewing comments in either DDE or on the Noridian Medicare Portal (NMP).
Further provider action recommended includes:
- Provide education regarding errors noted to applicable staff members.
- Verify documentation supports medical necessity of Healthcare Common Procedure Coding System (HCPCS) code G0277.
Summary
This service specific post-payment file is now closed for JF and Noridian will no longer request documentation for this review. Noridian will continue to monitor data analysis and perform medical review for medical necessity and appropriate coding practices.
If you have any other questions, contact the JF Provider Contact Center at 1-877-908-8431.
