Article Title

Hyperbaric Oxygen (HBO) Therapy – M-15B-R7

Contractor's Determination Number

M-15

Contractor Name

TrailBlazer Health Enterprises

Contractor Number

• Virginia Carrier – 00904.

Contractor Type

• Virginia Carrier – 00904.

AMA CPT/ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2010 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

• Virginia Carrier – 00904.

Original Article Effective Date

12/16/2001

Article Revision Effective Date

10/03/2010

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.

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 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 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 stated 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 of the 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.

· 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.

• 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).

Type of Bill Codes

N/A

Revenue Codes

N/A

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. 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

Other Comments

 N/A

Revision History Explanation

Number	Date	Explanation
R7	10/03/2010	Per provider request, added ICD-9-CM diagnosis code 909.2 (late effect of radiation) to the limited coverage for CPT/HCPCS codes C1300 and 99183; coding guidelines added to the limited coverage in the LCD and to the “Coding Guidelines” of the related article for ICD-9-CM codes 909.2 and 990 included requiring inclusion of diagnosis code(s) specific to the condition or the nature of the radiation effect, when known. Effective date: 10/01/2010.
R6	09/16/2009	Added statements in the LCD section titled “ICD-9-CM Codes That Support Medical Necessity” to clarify coding requirements for patients with diabetic wounds of the lower extremities. No change in coverage. Effective date: 09/01/2009.
R5	11/2006	Clarified coding of “Diabetic Wounds of the Lower Extremities” in Covered Conditions section of LCD with coding guideline information provided in the Article. No change in coverage. Effective date: 04/01/2003 per NCD 20.29
R4	08/29/2005	Per CR 3172 deleted bill type 22X effective 06/28/2004. Converted LMRP to LCD format as part of June 2005 Annual Policy Evaluation. Updated CMS references to IOM effective 10/01/2003.