Benefit Criteria to Change for Hyperbaric Oxygen Therapy for the CSHCN Services Program Effective November 1, 2012

Transcription

1 Benefit Criteria to Change for Hyperbaric Oxygen Therapy for the CSHCN Services Program Effective November 1, 2012 Information posted September 14, 2012 Effective for dates of service on or after November 1, 2012, benefit criteria will change for hyperbaric oxygen therapy (HBOT) services for the Children with Special Health Care Needs (CSHCN) Services Program. Benefits Changes for Code HBOT procedure code will no longer be diagnosis-restricted, but it will require prior. HBOT services must be provided in facilities that have experience in HBOT treatment of pediatric clients. The physician must be in constant attendance during the compression and decompression phases of each treatment and may not delegate this attendance. Both the facility s medical record and the client s medical record must contain documentation to support that there was a physician in attendance who provided supervision of the compression and decompression phases of the HBOT treatment. All documentation pertaining to HBOT is subject to retrospective review. HBOT Outpatient Facility Billing Requirements HBOT procedure code C1300 will be a benefit and may be reimbursed in the outpatient setting to hospital providers. Claims for procedure code C1300 must be submitted with revenue code 413 on the same claim. Claims that are submitted without revenue code 413 will be denied. The number of units that may be submitted for procedure code C1300 will be based on the length of time during which the patient receives treatment with hyperbaric oxygen. Each unit represents 30 minutes of HBOT. Hospitals should take into consideration the time spent during ascent, under pressure, during descent, and airbrakes, and then calculate the number of units as follows: The minimum amount of time that can be submitted for 1 unit is 16 minutes. Providers may not submit a claim if the time spent in the chamber is 15 minutes or less. For a claim for 1 unit, the client must have spent at least 16 minutes in the chamber but less than 45 minutes. On claims for more than 1 unit, each unit must represent a full 30 minutes except for the last unit, which must be for minutes.

2 Prior Authorization Requirements HBOT procedure codes and C1300 will require prior. Prior requests submitted for procedure code C1300 must also include revenue code 413. The CSHCN Services Program recognizes only the following indications for HBOT as approved by the Undersea & Hyperbaric Medical Society (UHMS): Air or gas embolism Carbon monoxide poisoning Clostridial myositis and myonecrosis (gas gangrene) Crush injuries, compartment syndrome and other acute traumatic ischemias Decompression sickness Central retinal artery occlusion Severe anemia Intracranial abscess Necrotizing soft-tissue infections Refractory osteomyelitis Delayed radiation injury (soft tissue and bony necrosis) Compromised skin grafts and flaps Diabetic foot ulcer A completed CSHCN Services Program Authorization and Prior Authorization Request Form must be signed and dated by the prescribing physician and maintained in the client s medical record. Prior must be obtained before the delivery date or date of the service; however, if the service is emergent, provided after hours or on a recognized holiday or weekend, services may be authorized when the request is submitted on the next working day. A complete CSHCN Services Program Authorization and Prior Authorization Request form must be received within these deadlines for to be considered. The CSHCN Services Program does not extend these deadlines for providers to correct incomplete prior requests. Note: CSHCN Services Program defines an emergency as the sudden onset of a lifethreatening situation in which a severe debilitating condition or death would result if immediate medical care were not provided. To avoid unnecessary denials, the physician must provide correct and complete information, including documentation of medical necessity for the service requested. The physician must maintain documentation of medical necessity in the client s medical record. CSHCN Services Program Authorization and Prior Authorization Requests must include documentation that is specific to each appropriate covered indication as listed in the table below and supports medical necessity. The units in the columns for procedure

3 codes C1300 and represent the maximum number of units that are allowed for that procedure code per prior. Example: In accordance with recommended protocols, a client with an air/gas embolus may receive up to 6 units (180 minutes) of HBOT over two treatments. One prior number may be issued for a quantity of 6 units for procedure code C1300 for the facility and 2 professional sessions for procedure code The 6 units of chamber time for procedure code C1300 may be divided in any manner across the two professional sessions. For procedure code 99183, the usual protocol is two 90-minute treatments. The facility bills 90 consecutive minutes (3 units) per HBOT treatment for procedure code C1300. The physician bills per treatment, which in this case would be 2 professional sessions for procedure code The following table includes the covered indications for prior requirements and limitations: Covered Indications Code C1300 Code Medical Necessity Documentation of the Following is Required Air or gas embolism 6 2 Evidence that gas bubbles are detectable by ultrasound, Doppler or other diagnostics Carbon monoxide poisoning - initial Carbon monoxide poisoning - one Clostridial myositis and myonecrosis (gas gangrene) Crush injury, compartment syndrome and other acute traumatic ischemias Decompression sickness Central retinal artery occlusion 15 5 Persistent neurological dysfunction secondary to carbon monoxide inhalation 9 3 Evidence of continuing improvement in cognitive functioning Evidence of unsuccessful medical and/or surgical wound treatment and positive Gramstained smear of the wound fluid Adjunct to standard medical and surgical interventions 28 1 Diagnosis based on signs and/or symptoms of decompression sickness after a dive or altitude exposure 36 6 Evidence of central retinal artery occlusion with treatment initiated within 24 hours of the occlusion.

4 Covered Indications Code C1300 Code Medical Necessity Documentation of the Following is Required Severe anemia Hgb less than 6.0 sustained secondary to hemorrhage, hemolysis, or aplasia, when the patient is unable to be cross matched or refuses transfusion because of religious beliefs. Intracranial abscess - initial 15 5 Adjunct to standard medical and surgical interventions when one or more of the following conditions exist: Multiple abscesses Abscesses in a deep or dominant location Compromised host Surgery contraindicated or patient is a poor surgical risk. Intracranial abscess - one Necrotizing soft tissue infections initial Necrotizing soft tissue infections - two s Refractory osteomyelitis - initial Refractory osteomyelitis - one Delayed radiation injury (soft tissue and bony necrosis) - initial 15 5 Evidence of improvement response and radiological findings Evidence of unsatisfactory response to standard medical and surgical treatment and advancement of dying tissue 15 5 Evidence that advancement of dying tissue has slowed Evidence of unsatisfactory clinical response to conventional multidisciplinary treatment 15 5 Evidence of improvement response Evidence of unsatisfactory clinical response to conventional treatment

5 Covered Indications Delayed radiation injury - one Compromised skin grafts and flaps - initial Compromised skin grafts and flaps - one Acute thermal burn injury - initial Acute thermal burn injury three s Diabetic foot ulcer - initial Diabetic foot ulcer - two s Code C1300 Code Medical Necessity Documentation of the Following is Required Evidence of improvement response Evidence the flap or graft is failing because tissue is/has been compromised by irradiation or there is decreased perfusion or hypoxia Evidence of stabilization of graft or flap Partial or full thickness burns covering greater than 20% of total body surface area OR with involvement of the hands, face, feet or perineum Evidence of continuing improvement response After at least 30 days of standard medical wound therapy, with a wound po2 less than 40 mmhg AND wound classified as Wagner grade 3 or higher. * Evidence of continuing healing and wound po2 less than 40 mmhg *Note: The following Wagner wound classification grades apply only to the diabetic foot ulcer indications: Grade 1: Superficial diabetic ulcer Grade 2: Ulcer extension - involves ligament, tendon, joint capsule or fascia (No abscess or osteomyelitis) Grade 3: Deep ulcer with abscess or osteomyelitis Grade 4: Gangrene to portion of forefoot Grade 5: Extensive gangrene of foot

6 Non-Covered Services CSHCN Services Program considers HBOT experimental and investigational for any indications other than the ones approved by the Undersea and Hyperbaric Medical Society (UHMS) and outlined in this article. Non-covered indications, include, but are not limited to, autism and traumatic brain injury. Limitations beyond those listed in the table above are considered experimental and investigational. Oxygen administered outside of a hyperbaric chamber, by any means, is not considered hyperbaric treatment. For more information, call the TMHP-CSHCN Services Program Contact Center at