23 Miss. Code. R. 202-5.1 - Hyperbaric Oxygen Therapy
A. The Division of
Medicaid defines Hyperbaric Oxygen Therapy (HBOT) as a modality in which the
beneficiary's entire body is placed into the hyperbaric chamber and exposed to
oxygen under increased atmospheric pressure.
1. The beneficiary is entirely enclosed in a
pressure chamber breathing 100% oxygen (O 2) at greater
than one atmosphere pressure.
2.
Either a mono-place chamber pressurized with pure O 2 or
a larger multi-place chamber pressurized with compressed air where the
beneficiary receives pure O 2 by mask, head tent, or
endotracheal tube may be used.
B. The Division of Medicaid covers systemic
HBOT in an inpatient or outpatient hospital setting in accordance with current
standards of the Undersea and Hyperbaric Medical Society (UHMS) and when
administered in a Food and Drug Administration (FDA) approved chamber.
C. The Division of Medicaid covers
HBOT for medical conditions that are FDA approved or that follow medically
accepted indications supported by one (1) or more of the official compendia as
designated by the Centers for Medicare and Medicaid (CMS) or the UHMS when the
following criteria are met:
1. A physician or
non-physician practitioner (NPP), practicing within their scope of practice,
must:
a) Order HBOT treatments which must
include the estimated number of treatments and duration,
b) Document medical necessity,
c) Establish the plan of care which must:
1) Specify the goals for HBOT and
2) Include revisions as appropriate with
justification for extending treatments.
2. A cardiopulmonary resuscitation (CPR) team
and a fully equipped emergency cart must be immediately available where the
hyperbaric chamber is located when a beneficiary is receiving HBOT in the event
of a complication.
3. Emergency
response procedures are in place that ensures timely beneficiary access to a
hospital or acute care facility capable of providing emergent clinical support
and treatment of any complications arising from hyperbaric therapy or, when
indicated, the beneficiary's underlying disease processes for outpatient
hospital HBOT facilities located on or off the hospital's campus.
D. The Division of Medicaid
requires HBOT treatment facilities to meet the UHMS standards for the number of
trained and credentialed hyperbaric medicine physicians and non-physician
providers on staff for appropriate treatment and medical care required by a
beneficiary.
1. The Division of Medicaid
defines:
a) Direct supervision as supervision
by a physician or non-physician provider (NPP) providing services within their
scope of practice and hospital-granted privileges, the knowledge, skills, and
ability in accordance with UHMS standards during a performed procedure in which
the physician or NPP must be immediately available to furnish assistance and
direction throughout the performance of the procedure.
b) Immediately available as being in close
physical proximity within the same building or connected building or structure,
to where HBO2 treatments are provided and able to personally and physically
attend to the chamber-side as soon as requested.
2. The Division of Medicaid requires a
physician or NPP to provide direct supervision and be immediately available to
the hyperbaric oxygen chamber(s) location while the beneficiary is receiving
HBOT
3. NPPs may supervise HBOT
services, if such service including definitive evaluation of the beneficiary is
included within their scope of practice, or if their required supervision or
collaborative agreement is with a physician qualified to provide HBOT services
who remains immediately available and if the NPP meets required educational
requirements.
E. The
Division of Medicaid does not cover topical application of oxygen with portable
HBOT chambers.
F. The Division of
Medicaid reimburses the:
1. Hospital per
beneficiary regardless if the HBOT is received in a mono or multi-place chamber
per thirty (30) minute interval.
2. Physician or NPP per beneficiary session
for attendance or supervision of HBOT.
G. The Division of Medicaid requires the
following documentation of medical necessity:
1. Must be maintained in the beneficiary's
record and available for review upon request.
2. Must be legible and include appropriate
beneficiary identification information and signature of the physician or
non-physician practitioner responsible for and providing care to the patient.
3. Must support the use of the
selected ICD-10-CM code(s) and CPT/HCPCS code must describe the service
performed.
4. Documentation that a
trained emergency response team is available and that the hospital setting
provides the required availability of intensive care unit (ICU) services that
could be needed to ensure the beneficiary's safety if a complication occurred.
5. Documentation present in the
clinical record must provide an accurate description and diagnosis of the
medical condition supporting that the use of HBOT is reasonable and medically
necessary. The medical documentation must include but is not limited to the
following:
a) An initial assessment, which
includes a history and physical that clearly substantiates the condition for
which HBOT is recommended. This should also include any prior medical, surgical
or HBOT treatments.
b)
Documentation of the procedure including ascent time, descent time and
pressurization level. There should be a treatment plan identifying timeline and
treatment goals.
c) Physicians'
progress notes that describe the physical findings, type(s) of treatment(s)
provided, number of treatments provided, the effect of treatment(s) received
and the assessment of the level of progress made toward achieving the
completion of established therapy goals.
d) Physician-to-physician communications or
records of consultations, additional assessments, recommendations or procedural
reports.
e) Laboratory reports
(cultures or Gram stains) that confirm the diagnosis of necrotizing fasciitis
are required and must be present as support for payment of HBOT.
f) X-ray findings and bone cultures
confirming the diagnosis of osteomyelitis are required and must be present as
support for payment of HBOT.
g)
Documentation to support the presence of gas gangrene as proven with laboratory
reports (Gram stain or cultures) and X-ray.
h) Documentation of date and anatomical site
of prior radiation treatments.
i)
Documentation supporting date of skin graft and compromised state of graft
site.
j) For diabetic wounds of
the lower extremity, the Wagner classification of the wound and the failure of
an adequate course (at least 30 days) of standard wound therapy must be
documented at the initiation of therapy.
k) Specific written record of the physician's
or NPP's direct supervision of the hyperbaric chamber while the beneficiary is
undergoing HBOT; and
l) Specific
written record of the availability of a trained CPR team and a fully equipped
emergency cart where the hyperbaric chamber is located while the beneficiary is
undergoing HBOT.
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