AI Solutions for Healthcare

Diving into Hyperbaric Oxygen Therapy (HBOT)

Hyperbaric oxygen therapy is a specialized treatment used in the medical profession to treat a wide range of conditions. For treatment, the patient is placed in the HBO chamber which is pressurized to two and a half to three times the normal atmospheric pressure to allow greater absorption of oxygen throughout the body. Patients who receive this specialized therapy are closely monitored and observed for oxygen toxicity or other serious side effects of HBO therapy.

The Procedure Codes
Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session
G0277: Hyperbaric oxygen under pressure, full body chamber, per 30-minute interval(s)
A4575: Topical hyperbaric oxygen chamber, disposable, note – this is considered investigational and may not be approved for coverage or payment criteria

Common FWA Related Schemes:
The Office of Inspector General has reviewed HBO therapy many times, most recently in 2017 at which time they found patients were receiving treatment for non-covered conditions, receiving treatment longer than medically necessary and the documentation did not support the treatment. Based on these findings we recommend monitoring the following areas in your claims:

    • Unsupported diagnosis for treatment or physician services
    • Excessive units of G0277 (greater than 4 units or 2 hours)
    • Performing topical HBO and billing it as traditional HBO therapy
    • High concentration of patients with long-term HBO
    • Billing 99183 and G0277 on the same date by the same provider (typically the facility would bill for the G0277)

Medicare Coverage Criteria:
HBO therapy coverage under Medicare, Medicare reimbursement for HBO therapy is limited to what is administered in a chamber and only for 15 conditions, including diabetic wounds of the lower extremities and chronic refractory osteomyelitis (chronic bone infections).  To view the National Coverage Determination (NDC 20:29) for CMS please see the link in the reference section below.

Review Approach:

    • Review your plan’s policies for commercial and governmental lines of business for coverage criteria.
    • Identify the outlier providers in terms of your professional vs facility spend for HBO therapy.
    • We have compiled a list of CMS for Medicare and Medicaid covered diagnosis codes commonly associated with HBO therapy as an addendum after this alert. Please remember when a diabetic patient with a wound received HBO therapy, two diagnoses need to be appended to the claim for Medicare, one for diabetes and the other specific to the wound to satisfy medical necessity.

Covered Single Diagnosis Codes:
A420 A421 A422 A4289 A429 A430 A431 A438 A439 A480 B471 B479 I742 I743 I745 L081 L598 M272 M278 M726 M86311 M86312 M86321 M86322 M86331 M86341 M86342 M86351 M86352 M86361 M86371 M8639 M86411 M86421 M86422 M86372 M8638 M86442 M86451 M86452 M86461 M86431 M86432 M86472 M8648 M8649 M86511 M86512 M86462 M86471M86531 M86532 M86541 M86542 M86551 M86552 M86522 M86582 M86571 M86572 M8658 M8659 M86552 M86561 M86621 M86622 M86631 M86641 M86611 M86612 M86652
M86661 M86662 M86671 M86642 M86651 M868X0 M868X1 M868X2 M868X3 M868X4 M868X5 M868X6 M868X7 M868X8 M8668 M8669 N0340 N3041 S35511A S35512A S45011AS45012A S45091A S45092A S45111A S45112A S45191A S45192A S45211A S45212A S45291A S471XXA S472XXA S5701XA S5702XA S5781XA S5782XA S6701XA S6702XA S67190A S67191AS67192A S67193A S67194A S67195A S67196A S67197A S6721XA S6722XA S6731XA S6732XA S6741XA S6742XA S75011A S75012A S75021A S75022A S75091A S75092A S7701XA S7702XA S7711XA S7712SA S7721XA S7722XA S85011A S85012A S85091A S850292A S8701XA S8702XA S8781XA S8782XA S9701XA S9702XA S97111A S97112A S97121A S97122A S9781XA S9782XAT573X1A T573X2A T573X3A T573X4A T5801XA T5802XA T5803XA T5804XA T5811XA T5812XAT5813XA T5814XA T582X1A T582X2A T582X3A T582X4A T588X1A T588X2A T588X3A T588X4A T5891XA T5892XA T5893XA T5894XA T650X1A T650X2A T650X3A T650X4A T7029XA T703XXAT790XXA T800XXA T86820 T86821 T86822 T86828 T870X1 T860X2 T871X1 T871X2 T872

Covered Dual Diagnosis Codes:
Set 1 [Diabetic conditions]

E1051 E1052 E10618 E10620 E10621 E10622 E10628 E1065 E1069 E1151 E1152 E11816 E11620 E11621 E11622 E11628 E1165 E1169 E1351 E1352 E13618 E13620 E13621 E13622 E13628

Set 2 [Secondary supported conditions with Set 1]
I7025 I70231 I70232 I70233 I70234 I70235 I70238 I70241 I70242 I70243 I70244 I70245 I70248 I70331 I70332 I70333 I7033 I70335 I70338 I70341 I70342 I70343 I70334 I70345 I70348 I70431 I70432 I70433 I70434 I70435 I70438 I70441 I70442 I70443 I70444 I70445 I70448 I70531 I70532 I70533 I70534 I70535 I70538 I70541 I70542 I70543 I70544 I70545 I70548
I70631 I70632 I70633 I70634 I70635 I70638 I70641 I70642 I70643 I70644 I70645 I70648 I70731 I70732 I70733
I70734 I70735 I70738 I70741 I70742 I70743 I70744 I70745 I70748 L97111 L97112 L97113 L97114 L97115 L97116 L97118 L97121 L97123 L97124 L97125 L97126 L97128 L97211 L97212 L97213 L97214 L97215 L97216 L97218 L97221 L97222 L97223 L97224 L97225 L97226 L97228 L97311 L97312 L97313 L97314 L97315 L97316 L97318 L97321 L97322 L97323 L97324 L97325 L97326 L97328 L97411 L97412 L97413 L97414 L97415 L97416 L97418 L97421 L97422 L97423 L97424 L97425 L97426 L97428 L97511 L97512 L97513 L97514 L97515 L97516 L97518 L97521 L97522 L97523 L97524 L97525 L97526 L97528 L97811 L97812 L97813 L97814 L97815 L97816 L97818 L97821 L97822 L97823 L97824 L97825 L97826 L97828

  1. CMS National Coverage Criteria: 20.29
  2. HHS Reports and Publications

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