Hyperbaric Oxygen Therapy 2003 Medicare Coverage Decision

Advances in Skin & Wound Care, Sep/Oct 2003 by Schaum, Kathleen D

The Medicare national coverage decision has expanded the use of hyperbaric oxygen (HBO) therapy to include coverage for the treatment of diabetic wounds of the lower extremities. This column will clarify a few Medicare reimbursement issues related to this new coverage.

Q: What ICD-9-CM diagnosis codes are covered for treatment of diabetic wounds of the lower extremities?

A: The ICD-9-CM codes acceptable as medical necessity are: 250.7, diabetes with peripheral circulatory disorders; 250.8, diabetes with other specified manifestations; 707.1, ulcer of lower limb, except decubitus; 707.10, ulcer of lower limb, unspecified; 707.12, ulcer of calf; 707.13, ulcer of ankle; 707.14, ulcer of heel and midfoot; 707.19, ulcer of other part of lower limb.

Be sure to include the fourth and fifth digits on the claim forms.

Q: If a hospital inpatient receives HBO therapy, what ICD-9-CM procedure code should be used?

A: 93.59-other immobilization, pressure, and attention to wound.

The hospital inpatient service is paid via the diagnosis-related group (DRG) payment system.

Q: I understand the new HBO coverage decision states that HBO can be used only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. What exactly does the coverage decision mean by "standard wound care"?

A: The coverage decision states that standard wound care for patients with diabetic wounds includes: assessment of vascular status and correction of any vascular problems in the affected limb, if possible; optimization of nutritional status; optimization of glucose control; debridement by any means to remove devitalized tissue; maintenance of clean, moist bed of granulation tissue with appropriate moist dressings; appropriate off-loading; necessary treatment to resolve any infection that might be present.

Clinicians and physicians should be careful to document all their standard wound care in the medical record. If a Medicare claim is rejected and the Medicare Summary Notice includes message 15.4, which states, "The information provided docs not support the need for this service or item," the provider should carefully review the ICD-9-CM diagnosis code(s) submitted and the medical record documentation.

One Medicare intermediary states the documentation must include:

* an initial assessment, which includes a medical history detailing the condition requiring HBO. The history should list prior treatment modalities, such as antibiotics and surgical interventions. This note should also list and/or describe any adjunctive treatment currently in progress.

* physician progress notes that indicate the physician was present throughout the treatment session

* communication between physicians regarding treatment plans (past, current, and future)

* culture reports when appropriate (osteomyelitis)

* HBO treatment records describing the physical findings, the treatment rendered, and the effect of treatment on the established goals of therapy.

Providers should verify the documentation requirements of their Medicare Carrier or Fiscal Intermediary.

Q: How often must wounds be evaluated during administration of HBO therapy?

*A: At least every 30 days, per the Medicare Coverage Decision. If the wound evaluation does not indicate measurable signs of healing within the past 30-day period of HBO treatment, Medicare will not cover continued HBO treatment.

Q: What HCPCS code should hospital outpatient departments paid by the Ambulatory Payment Classification (APC) system use to represent HBO therapy performed in the facility? What is the national APC payment rate for this code?

A: C1300-hyperbaric oxygen under pressure, full body chamber, per 30-minutc interval. The 2003 APC payment rate is $168.78 per 30-minute interval. The national unadjusted coinsurance is $33.76 per 30-minute interval.

Kathleen D. Schaum, MS

Kathleen D. Schaum, MS, is President of Kathleen D. Schaum & Associates, Inc., of Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her E-mail address: kathleendschaurn@bellsouth.net. Submit your questions for Payment Strategies by mail to: Kathleen D. Schaum, MS, 6491 Rock Creek Drive, Lake Worth, FL 33467. Information regarding payment is provided as a service to our readers, but does not guarantee that payment will be received. Providers are responsible for case-by-case documentation and justification of medical necessity.