Article Title

Hyperbaric Oxygen (HBO) Therapy – 4M-30AB-R5

Contractor’s Determination Number

4M-30AB

Contractor Name

TrailBlazer Health Enterprises

Contractor Number

• 04001 (04101, 04201, 04301, 04401, 04901).
• 04002 (04102, 04202, 04302, 04402).

Contractor Type

• MAC – Part A.
• MAC – Part B.

AMA CPT/ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply. Current Dental Terminology (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction

• CO.
• NM.
• OK.
• TX:
• Indian Health Service.
• End Stage Renal Disease (ESRD) facilities.
• Skilled Nursing Facilities (SNFs).
• Rural Health Clinics (RHCs).
• Transitioned WPS legacy providers.

Oversight Region

• Region IV.
• Region VI.

Original Article Effective Date

03/01/2008

03/21/2008

06/13/2008

Article Revision Effective Date

10/15/2011

Article Ending Effective Date

N/A

Article Text

Abstract

Hyperbaric Oxygen (HBO) therapy is a medical modality in which the patient’s entire body is exposed to 100 percent oxygen under increased atmospheric pressure greater than one atmosphere. This is delivered either in a monoplace chamber (pressurized with pure oxygen) or in a multiplace chamber, pressurized with compressed air where the patient receives pure oxygen by mask, head tent or endotracheal tube.

HBO was developed as a treatment for decompression illness and has been established as a primary therapy in treatment of medical disorders such as carbon monoxide poisoning and gas gangrene.

The use of HBO therapy is covered as adjunctive therapy 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.

Standard wound care in patients with diabetic wounds includes:

• Assessment of a patient’s 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 a clean, moist bed of granulation tissue with appropriate moist dressings.
• Appropriate off-loading.
• Necessary treatment to resolve any infection that might be present.

Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.

Part A Program Instructions:

Reasons for Denial

• Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.
• No payment will be allowed for HBO without documentation that a trained emergency response team is available and that the setting provides the required availability of (Intensive Care Unit) ICU services that could be needed to ensure the patient’s safety if a complication occurred.
• All other indications not listed in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the related LCD.
• The medical record does not verify that the service described by the CPT/HCPCS code was provided.  
• The service does not follow the guidelines of the related LCD.
• The service is considered:

• Investigational.     
• For cosmetic purposes.      
• For routine screening.    
• A program exclusion.   
• Otherwise not covered.    
• Never medically necessary.

Non-Covered Conditions per NCD 20.29

No program payment may be made for HBO in the treatment of the following conditions:

• Cutaneous, decubitus and stasis ulcers.
• Chronic peripheral vascular insufficiency.
• Anaerobic septicemia and infection other than clostridial.
• Skin burns (thermal).
• Senility.
• Myocardial infarction.
• Cardiogenic shock.
• Sickle cell anemia.
• Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency.
• Acute or chronic cerebral vascular insufficiency.
• Hepatic necrosis.
• Aerobic septicemia.
• Non-vascular causes of chronic brain syndrome (Pick’s disease, Alzheimer’s disease, Korsakoff’s disease).
• Tetanus.
• Systemic aerobic infection.
• Organ transplantation.
• Organ storage.
• Pulmonary emphysema.
• Exceptional blood loss anemia.
• Multiple sclerosis.
• Arthritic disease.
• Acute cerebral edema.

Topical Application of Oxygen

The topical application method of oxygen administration does not meet the definition of HBO therapy as indicated in the related LCD. Its clinical efficacy has not been established therefore, payment for this method will not be allowed.

Coding Guidelines

• Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits.

• To report these services, use the appropriate CPT/HCPCS code(s).
• All coverage criteria must be met before this service can be reimbursed by Medicare.
• Diagnosis(es) must be present on any claim submitted and must be coded to the highest level of specificity.
• The diagnosis code(s) must be representative of the patient’s condition.
• For diabetic wounds of the lower extremity, one of the ICD-9-CM codes for diabetic complications (250.70–250.73 or 250.80–250.83) must be listed in addition to a covered wound diagnosis (707.10–707.15 or 707.19) to indicate this condition.
• CPT code 99183 applies to Non-Outpatient Prospective Payment System (Non-OPPS) providers only.
• HCPCS code C1300 applies to Part A OPPS providers only.
• When billing medically necessary services due to a diagnosis of unspecified effects of radiation (990) or late effects of radiation (909.2), the specific diagnosis code(s) for the condition or nature of the effect or late effect of radiation must also be included on the claim and sequenced first, unless the specific condition is unknown (not documented in the medical record).
• Evaluation and management services and/or procedures (e.g., wound debridement) provided in a hyperbaric oxygen treatment facility in conjunction with a hyperbaric oxygen therapy session should be reported separately.
• Medicare requires that therapeutic procedures performed in a hospital outpatient setting, either on-campus or off-campus, be performed under the direct supervision of a physician. This means that the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician be present in the room when the procedure is performed.
• When billing for this service in a non-covered situation (e.g., does not meet indications of the related LCD), use the appropriate modifier (see below). To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.
• Modifiers:
• GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted but must be made available upon request.)
• GZ: Item or service expected to be denied as not reasonable and necessary. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN and the provider expects the item/service to be denied. All claim line items submitted with the GZ modifier will be denied automatically and will not be subject to complex medical review.)
• GY: Item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
• See also Bill Type and Revenue Code sections below. 

Part B Program Instructions:

Reasons for Denial

• Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.
• No payment will be allowed for HBO without documentation that a trained emergency response team is available and that the setting provides the required availability of (Intensive Care Unit) ICU services that could be needed to ensure the patient’s safety if a complication occurred.
• All other indications not listed in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the related LCD.
• The medical record does not verify that the service described by the CPT/HCPCS code was provided.  
• The service does not follow the guidelines of the related LCD.
• The service is considered:

• Investigational.     
• For cosmetic purposes.      
• For routine screening.    
•  A program exclusion.   
• Otherwise not covered.    
• Never medically necessary.

Non-Covered Conditions per NCD 20.29

No program payment may be made for HBO in the treatment of the following conditions:

• Cutaneous, decubitus and stasis ulcers.
• Chronic peripheral vascular insufficiency.
• Anaerobic septicemia and infection other than clostridial.
• Skin burns (thermal).
• Senility.
• Myocardial infarction.
• Cardiogenic shock.
• Sickle cell anemia.
• Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency.
• Acute or chronic cerebral vascular insufficiency.
• Hepatic necrosis.
• Aerobic septicemia.
• Non-vascular causes of chronic brain syndrome (Pick’s disease, Alzheimer’s disease, Korsakoff’s disease).
• Tetanus.
• Systemic aerobic infection.
• Organ transplantation.
• Organ storage.
• Pulmonary emphysema.
• Exceptional blood loss anemia.
• Multiple sclerosis.
• Arthritic disease.
• Acute cerebral edema.

Topical Application of Oxygen

The topical application method of oxygen administration does not meet the definition of HBO therapy as indicated in the related LCD. Its clinical efficacy has not been established therefore, payment for this method will not be allowed.

Coding Guidelines

• Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits.

• To report these services, use the appropriate CPT/HCPCS code(s).
• All coverage criteria must be met before this service can be reimbursed by Medicare.
• Diagnosis(es) must be present on any claim submitted and must be coded to the highest level of specificity.
• The diagnosis code(s) must be representative of the patient’s condition.
• For diabetic wounds of the lower extremity, one of the ICD-9-CM codes for diabetic complications (250.70–250.73 or 250.80–250.83) must be listed in addition to a covered wound diagnosis (707.10–707.15 or 707.19) to indicate this condition.
• CPT code 99183 applies to Non-Outpatient Prospective Payment System (Non-OPPS) providers only.
• When billing medically necessary services due to a diagnosis of unspecified effects of radiation (990) or late effects of radiation (909.2), the specific diagnosis code(s) for the condition or nature of the effect or late effect of radiation must also be included on the claim and sequenced first, unless the specific condition is unknown (not documented in the medical record).
• Evaluation and management services and/or procedures (e.g., wound debridement) provided in a hyperbaric oxygen treatment facility in conjunction with a hyperbaric oxygen therapy session should be reported separately.
• Medicare requires that therapeutic procedures performed in a hospital outpatient setting, either on-campus or off-campus, be performed under the direct supervision of a physician. This means that the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician be present in the room when the procedure is performed.
• When billing for this service in a non-covered situation (e.g., does not meet indications of the related LCD), use the appropriate modifier (see below). To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.
• Modifiers:
• GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted but must be made available upon request.)
• GZ: Item or service expected to be denied as not reasonable and necessary. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN and the provider expects the item/service to be denied. All claim line items submitted with the GZ modifier will be denied automatically and will not be subject to complex medical review.)
• GY: Item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
• Bill Type and Revenue Codes below DO NOT apply to Part B.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

13X, 85X

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.

0413

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
99183©	Hyperbaric oxygen therapy (Non-OPPS)
C1300	Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval (OPPS)

Other Comments

N/A