Hyperbaric oxygen therapy (HBOT) is an intervention in which an individual breathes near 100% oxygen intermittently while inside a hyperbaric chamber that is pressurized to greater than sea level pressure (1 atmosphere absolute). HBOT has been proven beneficial for treating multiple conditions and is covered by Medicare and commercial insurance carriers.
Conditions treatable with HBOT:
- Air or gas embolism
- Carbon monoxide poisoning
- Clostridial myositis and mynonecrosis (gas gangrene)
- Crush injury, compartment syndrome and other acute traumatic ischemia
- Decompression sickness
- Arterial insufficiencies
- Severe anemia
- Intracranial abscess
- Necrotizing soft tissue infections
- Osteomyelitis (refractory)
- Delayed radiation injury (soft tissue and bony necrosis)
- Compromised grafts and flaps
- Acute thermal burn injury
- Idiopathic sudden sensorineural hearing loss
Medicare and most commercial insurance carriers publish and follow specific coverage determination medical policies for HBOT, which are essential for the providers and billing staff to ensure reimbursement for HBOT services.
These policies provide valuable information for provider’s medical documentation and support medical billing’s inquiries for further supportive documentation. For example, if a patient presents with osteoradionecrosis, per Medicare’s National Coverage Determination (NCD) 20.29, HBOT must be used as an adjunct to conventional treatment. To ensure reimbursement, the provider’s documentation must state the specific diagnosis and the adjunctive treatment the patient is also undergoing in addition to the recommended HBOT.
It is also helpful to have medical records from the referring provider to support the adjunctive treatment or prior failed treatment in the patient’s medical record.
Prior to the initiation of HBOT, providers may initiate a pre-determination with commercial insurance companies. This is a benefit to the provider, as the pre-determination process is an extensive review of the medical records to determine whether the patient meets the criteria outlined in the medical policy to undergo HBOT.
After obtaining approval of treatment through the pre-determination process, a pre-certification for HBOT should be obtained. Undergoing both the pre-determination and pre-certification processes results in a higher likelihood of reimbursement. Unfortunately, Medicare does not have a pre-determination process. Medicare is currently testing a pre-certification process for non-emergent HBOT in New Jersey, Illinois and Michigan; however, the testing is still ongoing and the results have not been published.
While the pre-determination and pre-certification processes grant approval from commercial insurance carriers, all approval correspondences state the approval does not guarantee reimbursement. It is essential that the patient and the provider understand that an approval letter does not equal reimbursement.
The Department of Health and Human Services Office of Inspector General (OIG) conducted audits on paid claims in 2013 and 2014. An audit of one Medicare administrative contractor, Wisconsin Physicians Service (WPS), found a high volume of paid outpatient claims containing HBOT services. The OIG review selected a stratified random sample of 120 outpatient claims out of 44,940 that contained HBOT services to Medicare beneficiaries in 2013 and 2014. Review of medical records for compliance with Medicare requirements found 73 providers’ documentation was noncompliant.
Of the 120 claims audited, 102 totaling $300,789 were reimbursed in error, according to the OIG. The OIG estimated that $42.6 million was reimbursed in error for HBOT services for those two years. Following the audit, the OIG made four recommendations to WPS to save millions in future reimbursement:
- Recover the appropriate portion of the $300,789 in identified Medicare overpayment
- Notify the providers responsible for the 44,820 non-sampled claims with potential overpayments estimated at $42.3 million, so that those providers can investigate and return any identified overpayments
- Identify and recover any improper payments for HBOT made after the audit period
- Strengthen its policies and procedures for making payments for HBOT
While there is no guarantee of reimbursement when a provider delivers HBOT services, the best approach to ensure reimbursement is to locate and familiarize yourself with Medicare NCD 20.29 and commercial insurance carriers’ policies. The best practice for medical providers and medical billing staff is to develop a comprehensive internal guideline for all staff to follow before and while administering HBOT. This internal guideline may outline the pre-determination, pre-certification, verification of diagnosis coverage with insurance policy, verification of complete medical records supporting the diagnosis, as well as consistent medical documentation supporting the patient’s progress while undergoing HBOT services.
Providers and billing staff who are knowledgeable in insurance policies and documentation requirements and follow a comprehensive internal guideline have a higher likelihood of ensuring reimbursement while lessening the probability of later recoupment.