Pulmonology Coding Alert

Hyperbaric oxygen therapy (HBO) a medical treatment in which a client breathes pure oxygen under greater-than-normal atmospheric pressure is a relatively new procedure that is gaining in popularity. Perhaps because HBO is relatively rare, it seems to be a prime target for payers seeking to minimize costs. Nevertheless, there are codes that are being paid.

Currently, there are about 500 HBO chambers in the United States. An HBO client is placed inside a hyperbaric chamber, which is then pressurized with medical-quality air, similar to the pressurized cabin of a jet airplane. This treatment can be performed by a variety of doctors in an inpatient or outpatient setting. It leads to a substantial increase in the amount of oxygen carried in all body fluids including plasma, cerebrospinal fluid, and lymph and intracellular fluids. It can be used in wound healing and as part of an overall medical care plan treating a wide variety of illnesses and injuries. HBO most often is used by environmental doctors but critical care doctors, pulmonologists and anesthesiologists are being trained for it as well.

What Are the HBO Reimbursement Issues?

Medicare approves the treatment for a few respiratory- related conditions such as 986 (toxic effect of carbon monoxide), 444.xx (arterial embolism and thrombosis) and 993.3 (caisson disease [e.g., decompression sickness]). Coders should be cautioned that some of the earlier communications from Health Care Financing Administration (HCFA) contained errors, such as including decompression sickness caused by altitude as a covered condition, when in fact it should have been decompression sickness caused by diving.

The standard code for use of this therapy is 99183 (physician attendance and supervision of hyperbaric oxygen therapy, per session), with each new session using a separate instance of the same code. Any pretreatment, patient prep or patient education should be billed under the appropriate evaluation and management (E/M) code.

In fact, because many facilities reported that a physician is not always necessary to perform the procedure, a new code was established recently, G0167 (hyperbaric oxygen treatment not requiring physician attendance, per treatment session). Reimbursement for this code is left to the carriers discretion, so it is important to check before authorizing the service without a physician present. According to Caroline E. Fife, MD, associate professor, department of anesthesiology at the University of Texas in Houston and immediate past president of the Undersea Hyperbaric Medical Society (UHMS), the new code is a little misleading. It is particularly confusing to require a physician to generate a charge for which there is a practice-expense reimbursement, but for which no actual work is being done.

Who Can Perform HBO?

Credentialing and physician attendance are two of the more hotly contested concerns among HBO advocates and a potential source of real confusion among coders.
Regional carriers generally differ in their credentialing requirements for attending physicians. HCFA was at one time establishing requirements for credentialing physicians, based on those that now exist in Texas, but has since backed off. Last year, according to Leon Greenbaum, MD, executive director of the Kensington, Md.-based UHMS, the American Medical Association (AMA) established the foundations for medical professional certification in the procedure.

Because there is now a code for physician nonattendance, G0167, knowing what physician attendance actually means is an increasing source of confusion. A UHMS survey revealed a variety of reimbursement practices across the country, including differing physician attendance requirements. Many of the local carrier policies, according to the survey report, addressed the issue of physician attendance. Many simply state that 99183 means physician attendance and supervision, per session. Some go into detail. For example, Utah states that the physician needs to write a note at the beginning, at least every 30 minutes during each patient treatment, and at the end, and have a response time of one minute in the event of emergency. Arkansas ...requires that the physician be in continuous attendance within the immediate hyperbaric oxygen area (e.g., within the same room as the hyperbaric oxygen monoplace chamber, or within the hyperbaric oxygen multiplace chamber). And, there are some local payers that will cover the procedure only in the setting of a hospital, either inpatient or outpatient.

Providers Await Final Rules

Richard Moon, MD, medical director for the Center for Hyperbaric Medicine and Environmental Physiology at Duke University, states that keeping up with HBO reimbursement issues is an ongoing concern. And because HBO is relatively rare, it is a prime target for payers seeking to minimize costs. Even though, according to Moon, a large percentage of the population of patients currently treated with HBO really dont have any other options, particularly cases of chronic, unremitting problems that cannot be treated with surgery.

An important note in the HCFA interim policy states: HBO therapy should not be a replacement for other standard successful therapeutic measures. If the treatment will lead to repair, the rationale certainly exists for using HBO for a condition such as acute thermal and chemical pulmonary damage, which is a specifically stated noncovered condition.

HCFA also cautions that the treatment should range from less than a week to several months, and carriers are advised to review and document the medical necessity for the use of HBO for more than two months, regardless of the condition of the patient, before further reimbursement is made.

Negotiations between HCFA and advocates of the procedures are continuing. As a result, the reimbursement rate for HBO has changed a number of times over the past two years. UHMS is a good source for determining the latest rates.

According to Greenbaum, HCFAs final instructions for HBO, which were due first in January then in July, have been delayed again until August. A HCFA program memorandum, effective this April, reiterates existing interim reimbursement policy. The best advice is that you check with your local carrier before you use HBO.