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1 Page 1 of 11 Deborah Rondeau From: Saved by Windows Internet Explorer 7 Sent: Saturday, August 23, :20 PM Subject: FUTURE ARTICLE : Hyperbaric Oxygen Therapy (HBO Therapy) - Supplemental Instructions Article (SIA) (A44555) Hyperbaric Oxygen Therapy (HBO Therapy) - Supplemental Instructions Article (SIA) (A44555) Contractor Information Contractor Name National Government Services, Inc. Contractor Number Number Type State(s) FI IN FI IL FI KY FI ME FI MA FI NH, VT FI OH FI WI FI MI FI VA, WV RHHI AS, CA, CNMI, GU, HI, NV Carrier IN Carrier KY MAC CT Part A MAC CT Part B MAC NY Part A MAC NY Part B MAC NY- Part B MAC NY Part B Contractor Type

2 Page 2 of 11 Carrier Fiscal Intermediary MAC Part A MAC Part B Article Information Article ID Number A44555 Article Type Article Key Article Yes Article Title Hyperbaric Oxygen Therapy (HBO Therapy) - Supplemental Instructions Article (SIA) AMA CPT / ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2007 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 Number Type State(s) FI IN FI IL FI KY FI ME FI MA FI NH, VT

3 Page 3 of FI OH FI WI FI MI FI VA, WV AS, CA, CNMI, GU, HI, NV RHHI Carrier IN Carrier KY MAC CT Part A MAC CT Part B MAC NY Part A MAC NY Part B MAC NY- Part B MAC NY Part B Original Article Effective Date 12/01/2007 Article Revision Effective Date 07/18/2008 Article Text The information in this Supplemental Instructions Article (SIA) contains coding or other guidelines that complement the Local Coverage Determination (LCD) for Hyperbaric Oxygen Therapy (HBO Therapy. The LCD can be accessed on our contractor Web site at It can also be found on the Medicare Coverage Database at 1. Abstract: For purposes of coverage under Medicare, hyperbaric oxygen (HBO) therapy is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. (i.e., the patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O 2 ) at greater than one atmosphere (atm) pressure. Either a monoplace chamber pressurized with pure O 2 or a larger multiplace chamber pressurized with compressed air where the patient receives pure O 2 by mask, head tent, or endotracheal tube may be used. Topical application of oxygen does not meet the definition of HBO therapy as

4 Page 4 of 11 stated above. Also, its clinical efficacy has not been established. Therefore, no Medicare reimbursement may be made for the topical application of oxygen. Cross reference: section of the CMS Pub 100-3, Medicare National Coverage Determinations Manual. 2. Coding Guidelines: General Guidelines Procedure codes may be subject to Nationa Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to NCCI and OPPS requirements prior to billing Medicare. Advance Beneficiary Notification (ABN) Modifier Guidelines: Services not meeting medical necessity guidelines should be billed with modifier -GA or -GZ. The GA modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The - GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN should not be used. A waiver such as the Notice of Exclusions from Medicare Benefits (NEMB) Form CMS may be used. The NEMB Form CMS is available online at or Carrier Guidelines The diagnosis code(s) must best describe the patient's condition for which the service was performed. Claims for CPT code are payable under Medicare Part B in the

5 Page 5 of 11 following places of service: office (11), inpatient hospital (21), hospital outpatient hospital (22) and independent clinic (49). According to CPT coding guidelines, 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. ICD-9-CM codes 040.0, , , , , and indicate critically ill patients. Claims for CPT code with one of these diagnoses billed for services rendered in any place of service other than the inpatient hospital (21), will be denied as medically unnecessary. Intermediary Guidelines Guidelines for claims submitted on UB-04 to the Fiscal Intermediary Diagnostic tests, items and procedures are often ordered based on the patient's sign and/or symptom. When medical necessity for the service is justified by a sign or symptom that differs from the final diagnosis, the ICD- 9-CM code for the sign or symptom is best reported in Form Locator 76 on the UB-04 claim form. Diagnosis codes for signs or symptoms may also be indicated in fields (See CMS Publication , Medicare Program Integrity Manual, Chapter 3, Section for additional instructions.) Providers should report the patient's principal admitting diagnosis in Form Locator (FL) 67 of the UB-04. Additional or secondary diagnoses may be recorded in FLs 67A 67Q. For inpatient hospital claims subject to QIO review, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication , Medicare Program Integrity Manual, Chapter 25, Section 75 for additional instructions.) Providers should report the patient's reason for visit (admitting diagnosis) on outpatient bills in Form Locator 76 of the UB-04. The patient's reason for visit information should be reported for all unscheduled outpatient visits when revenue codes 045X, 0516 or 0526 are present. The ICD-9-CM diagnosis code describing the patient's stated reason for seeking care (or as stated by the patient's representative) at the time of outpatient registration should be used. (See CMS Publication , Medicare Program Integrity Manual, Chapter 3, Section for additional instructions.) Bill Type Guidelines CMS Publication , Medicare Claims Processing Manual, Chapter 9, Section 100(B) states that no type of technical services, such as a technical component of a diagnostic or screening service, is ever billed on TOBs 71x or

6 Page 6 of 11 73x...Technical services/components associated with professional services/components performed by independent RHCs or FQHCs are billed to Medicare carriers Technical services/components associated with professional services/components performed by provider-based RHCs or FQHCs are billed by the base-provider on the TOB for the base-provider and submitted to the FI. Revenue codes 096X, 097X and 098X are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the CAH must bill the FI using revenue codes 096X, 097X or 098X. 1. Claims for HBO therapy should be submitted on Form CMS-1450 or its electronic equivalent with the following information: a. Applicable Bill Types The applicable hospital bill types are 11X, 13X and 85X. b. Procedural Coding c Physician attendance and supervision of hyperbaric oxygen therapy, per session. d. C1300 Hyperbaric oxygen under pressure, full body chamber, per 30-minute interval. HCPCS codes are shown in FL 44 of the Form CMS-1450 or the electronic equivalent. 1. HCPCS code C1300 is not available for use other than in a hospital outpatient department. In skilled nursing facilities (SNFs), HBO therapy is part of the SNF PPS payment for beneficiaries in covered Part A stays. 2. For hospital inpatients, HBO therapy is reported under revenue code 940 without any HCPCS code. For inpatient services, show ICD-9-CM procedure code in FL 80 and Critical access hospitals (CAHs) (Bill type 85X) are paid under a

7 Page 7 of 11 reasonable cost based system, as required under section 1834(g) of the Social Security Act and are excluded from the Outpatient Prospective Payment System. CAHs are required to report HCPCS only for services not paid on a reasonable cost basis. (CMS Publication 100-4, Medicare Claims Processing Manual, Chapter 4, Section 20.1) a. For critical access hospitals (CAHs) not electing Method I, HBO therapy is reported under revenue code 0940 without any HCPCS code. b. For CAHs electing Method II, HBO therapy is reported under revenue code 940 along with CPT code CPT code is billed 1 unit per session. 1. Calculating units for HCPCS code C1300: Hospital outpatient departments providing hyperbaric oxygen (HBO) therapy report this service using HCPCS code C1300, HBO under pressure, full body chamber, per 30 minute interval. Effective January 1, 2005, the following may be included in calculating the total number of 30-minute intervals billable under HCPCS code C1300: (1) time spent by the patient under 100% oxygen; (2) descent; (3) air breaks; and (4) ascent. NOTE: A physician order for a 90-minute HBO treatment typically means that the physician desires that the patient be placed under 100% oxygen for 90 minutes. In order to safely achieve 100% oxygen for 90 minutes, additional time may be needed to provide for the descent, air breaks, and ascent. Therefore, the total number of billable 30-minute intervals would not be based solely on the amount of time noted on the physician order. In calculating how many 30-minute intervals to report, hospitals should take into consideration the time spent under pressure during descent, air breaks, and ascent. Additional units may be billed for sessions requiring at least 16 minutes of the next 30-minute interval. For example, 2 units of HCPCS code C1300 should be billed for a session in duration of between 46 and 75 minutes, while 3 units should be billed for a session in duration of between 76 and 105 minutes. Furthermore, 4 units of HCPCS code C1300 should be billed for a session in duration of between 106 and 135 minutes. HBO is typically prescribed for an average of 90 minutes, which hospitals should report using appropriate units of HCPCS code C1300 in order to properly bill for full body HBO therapy. In general, we do not expect that a physician order for 90 minutes of HBO therapy would exceed 4 billed units of HCPCS code C1300.

8 Page 8 of OPPS does not apply to claims for every type of bill submitted by Medicare-certified providers. The following guidelines pertain to claims for bill types that are subject to OPPS: a. Hospitals are required to include HCPCS codes for all services paid under OPPS. b. Every effort should be made to report all services performed on the same day on the same claim to assure proper payment under OPPS. Claims submitted for the same date of service will be returned to the provider (except duplicates or those containing condition code 20 or 21) with a notification that an adjustment bill should be submitted. (CMS [formerly HCFA] Transmittal A-00-36, June, 2000) Billing Requirements for Carriers and Intermediaries: 1. Claims for hyperbaric oxygen therapy for patients with diabetic wounds of the lower extremities require both a diagnosis related to diabetes (ICD-9-CM codes and ) and a diagnosis describing the wound ( ). Claims for hyperbaric oxygen therapy filed with a diagnosis in the range without a diagnosis indicating a diabetic condition (ICD-9-CM codes and ) will be denied as not covered according to the National Coverage Determination. 2. Specific billing instructions for hyperbaric oxygen therapy are found in CMS Publication 100-4, Chapter 32, Section and CMS Change Request 3632, published December 30, Instructions taken from this manual and the change request are in italics throughout this article. Coverage Topic Doctor Office Visits Hospital Care (Inpatient) Outpatient Hospital Services Coding Information 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 article does not apply to that Bill Type.

9 Page 9 of 11 Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims. 11x Hospital-inpatient (including Part A) 13x Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) 85x Special facility or ASC surgery-rural primary care hospital (eff 10/94) 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 article 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 article should be assumed to apply equally to all Revenue Codes. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes. All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review. Revenue codes only apply to providers who bill these services to the fiscal intermediary. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier (for use with Bill Types 11X and 13X), 0940 (for use with Bill Type 85X) and 096X, 097X, or 098X (for professional services in which the professional has reassigned billing rights to a Critical Access Hospital [CAH] choosing the optional method of billing). Revenue codes 096X, 097X and 098X are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the

10 FUTURE ARTICLE : Hyperbaric Oxygen Therapy (HBO Therapy) - Supplemental Ins... Page 10 of 11 optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the CAH must bill the FI using revenue codes 096X, 097X or 098X Respiratory services-hyperbaric oxygen therapy 0940 Other therapeutic services-general classification 0960 Professional fees-general classification 0969 Professional fees-other 0982 Professional fees-outpatient services 0987 Professional fees-hospital visit CPT/HCPCS Codes PHYSICIAN ATTENDANCE AND SUPERVISION OF HYPERBARIC OXYGEN THERAPY, PER SESSION C1300 HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL Other Information Other Comments These supplemental instructions apply within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims. Revision History Explanation This SIA was revised to add the Jurisdiction 13 (J-13) MAC contractor numbers. This revised Supplemental Instructions Article (SIA) is effective for all National Government Services jurisdictions on July 18, 2008 with these exceptions: for Connecticut Part B the SIA is effective on August 1, 2008; for Upstate New York Part B, the SIA is effective on September 1, 2008; and for New York and Connecticut Part A, the SIA is effective on November 14, 2008.For New York Part A (contract 00308), the

11 FUTURE ARTICLE : Hyperbaric Oxygen Therapy (HBO Therapy) - Supplemental Ins... Page 11 of 11 content of this SIA is currently in effect but the SIA will be transferred to the J-13 contract number on November 14, Related Documents LCD(s) L Hyperbaric Oxygen Therapy (HBO) Close