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Hyperbaric Medicine / HMOs / ICD

Kathy Posted Sun 28th of August, 2011 23:26:08 PM

I have a patient who's insurance is an HMO. She is recieving hyperbaric oxygen x20 under an authorization which reflects the following:
ICD: 686.01 pyoderma / 459.81 venous insufficiency /
729.39 panniculitis

The primary diagnosis, 686.01, has been documented as healed on her 14th treatment. My question is, how do I accuratley code the remaining 6 treatments she recieved and still keep the authorization in tact?? I am wondering if the following (in this order) would work:
686.01 / V58.9 (unspecified aftercare) / 459.81 / 729.39

Professional insight would be greatly appreciated!!! Thanks!

SuperCoder Answered Mon 29th of August, 2011 20:16:48 PM

We should continue the initial diagnosis over the entire episode of care which involves the recovery at any session.
But the General Guidelines of Coverage:
Covered Conditions
Program reimbursement for HBO therapy will be limited to that which is administered in a chamber (including the one man unit) and is limited to the following conditions:
1. Acute carbon monoxide intoxication, (ICD-9 -CM diagnosis 986).
2. Decompression illness, (ICD-9-CM diagnosis 993.2, 993.3).
3. Gas embolism, (ICD-9-CM diagnosis 958.0, 999.1).
4. Gas gangrene, (ICD-9-CM diagnosis 0400).
5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. (ICD-9-CM diagnosis 902.53, 903.01, 903.1, 904.0, 904.41.)
6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened. (ICD-9-CM diagnosis 927.00- 927.03, 927.09-927.11, 927.20-927.21, 927.8-927.9, 928.00-928.01, 928.10-928.11, 928.20-928.21, 928.3, 928.8-928.9, 929.0, 929.9, 996.90- 996.99.)
7. Progressive necrotizing infections (necrotizing fasciitis), (ICD-9-CM diagnosis 728.86).
8. Acute peripheral arterial insufficiency, (ICD-9-CM diagnosis 444.21, 444.22, 444.81).
9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), (ICD-9CM diagnosis 996.52; excludes artificial skin graft).
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, (ICD-9-CM diagnosis 730.10-730.19).
11. Osteoradionecrosis as an adjunct to conventional treatment, (ICD-9-CM diagnosis 526.89).
12. Soft tissue radionecrosis as an adjunct to conventional treatment, (ICD-9-CM diagnosis 990).
13. Cyanide poisoning, (ICD-9-CM diagnosis 987.7, 989.0).
14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment, (ICD-9-CM diagnosis 039.0-039.4, 039.8, 039.9).
15. Diabetic wounds of the lower extremities in patients who meet the following three criteria:
1. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
2. Patient has a wound classified as Wagner grade III or higher; and
3. Patient has failed an adequate course of standard wound therapy.
The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient's vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.

Noncovered Conditions
All other indications not specified under 270.4(A) are not covered under the Medicare program. No program payment may be made for any conditions other than those listed in 270.4(A).
No program payment may be made for HBO in the treatment of the following conditions:
1. Cutaneous, decubitus, and stasis ulcers (ICD-9 -CM diagnosis 707.0.)
2. Chronic peripheral vascular insufficiency (ICD-9 -CM diagnosis 443.8, 459.81)
3. Anaerobic septicemia and infection other than clostridial (ICD-9 -CM diagnosis 038.3)
4. Skin burns (thermal). (ICD-9 -CM diagnosis 692.71, 692.76 - 692.79, 940 - 949.5)
5. Senility. (ICD-9 -CM diagnosis 797)
6. Myocardial infarction. (ICD-9 -CM diagnosis 410 - 4109.2)
7. Cardiogenic shock.. (ICD-9 -CM diagnosis 7855.1)
8. Sickle cell anemia. (ICD-9 -CM diagnosis 2826.9)
9. Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency (ICD-9 -CM diagnosis.5188.2)
10. Acute or chronic cerebral vascular insufficiency. (ICD-9 -CM diagnosis 434, 437.0, 437.4)
11. Hepatic necrosis. (ICD-9 -CM diagnosis 537.8, 537.9)
12. Aerobic septicemia. (ICD-9 -CM diagnosis 038.8, 038.9)
13. Nonvascular causes of chronic brain syndrome (Pick's disease, Alzheimer's disease, Korsakoff's disease) (ICD-9 -CM diagnosis. 291.2, 331.0, 331.1)
14. Tetanus. (ICD-9 -CM diagnosis 037, 771.3)
15. Systemic aerobic infection. (ICD-9 -CM diagnosis
16. Organ transplantation.
17. Organ storage.
18. Pulmonary emphysema. (ICD-9 -CM diagnosis 492)
19. Exceptional blood loss anemia. (ICD-9 -CM diagnosis 285)
20. Multiple Sclerosis. (ICD-9 -CM diagnosis 340)
21. Arthritic Diseases. (ICD-9 -CM diagnosis (711.0 - 711.99)
22. Acute cerebral edema. (ICD-9 -CM diagnosis (348.5)
Reasonable Utilization Parameters
Make payment where HBO therapy is clinically practical. HBO therapy should not be a replacement for other standard successful therapeutic measures. Depending on the response of the individual patient and the severity of the original problem, treatment may range from less than 1 week to several months duration, the average being two to four weeks. Review and document the medical necessity for use of hyperbaric oxygen for more than two months, regardless of the condition of the patient, before further reimbursement is made.
Topical Application of Oxygen
This method of administering oxygen does not meet the definition of HBO therapy as stated above. Also, its clinical efficacy has not been established. Therefore, no Medicare reimbursement may be made for the topical application of oxygen.
CMS Transmittal AB-02-183, Change Request 2388 also contains the following information:
CMS has concluded that special supervision and credentialing requirements should not be imposed on physicians who perform HBO therapy. You may not impose a higher level of supervision than direct supervision as is required for all "incident to" therapies. CMS encourages physicians who perform HBO therapy to obtain adequate training in the use of HBO therapy and in advanced cardiac life support.

Kathy Posted Thu 01st of September, 2011 14:26:38 PM

Thanks for the clarification Sanjit. You are greatly appreciated!!! Have a great day.

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