HBO Therapy Services Documentation Requirements - JF Part A
Hyperbaric Oxygen (HBO) Therapy Services Documentation Requirements
It is expected that the 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:
- Wagner grade classification (must be Wagner grade III or higher) with diagnostic testing to support Wagner grade
- Patient has type 1 or 2 diabetes and has lower extremity wound due to diabetes
- NCD does not cover surgical or injuries complicated by diabetes
- Documentation supporting prior failed treatment using standard wound care
- Documentation supporting there were no measurable 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
- 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 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
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.
- Noridian Medical Review - Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the Hyperbaric Oxygen (HBO) Therapy webpage for additional information and resources.
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.
