Tag Archives: hyperbaric oxygen therapy

Hyperbaric oxygen therapy as adjunct therapy for wound care

Why would a patient with a wound spend almost 2 hours a day, 5 days a week, in a locked chamber receiving 100% oxygen? The answer is that medical grade hyperbaric oxygen therapy (HBOT) can be a valuable adjunct therapy for selected types of wounds.
In this article, I’ll focus on hospitals and clinics that follow guidelines from the Undersea & Hyperbaric Medical Society as I give you a brief overview of how HBOT works and its use in wound care.

How HBOT helps in wound healing

The air that we breathe is 21% oxygen. With HBOT, patients are placed in a sealed chamber, where they breathe 100% oxygen under pressure. The pure oxygen saturates blood cells and blood plasma, which in turn increases oxygen supply to the tissues—including the wound being treated. HBOT can reduce the time it takes for a wound to heal by:
• promoting collagen deposition, enhancing epithelial cell migration, and decreasing local tissue edema

killing anaerobic bacteria in tissue and bones

preventing additional bioburden by increasing leukocyte production and activity

enhancing angiogenesis (development of new blood vessels), which brings more blood and healing factors to the wound. Keep in mind that although angiogenesis can be beneficial for wounds with insufficient perfusion, HBOT is not an alternative to revascularization.

Not all wounds benefit from HBOT. (See Types of wounds treated with hyperbaric oxygen therapy.)

Length of treatment

The average treatment time is 110 minutes in the HBOT chamber: about 10 minutes for a patient to reach the appropriate pressure, 90 minutes at the pressure, and 10 minutes to return the patient to normal pressure. Times can be expedited in the case of an emergency; for example, a patient can be out of the chamber in 7 minutes if he or she experiences a serious reaction. The average length of treatment is 30 visits, normally 5 days a week for 6 weeks.

A safety director monitors the HBOT chambers and treatment area, and a supervising provider is present at all times to monitor each treatment and prevent or manage emergencies.

Possible negative effects

Overall, HBOT is a safe treatment for serious wounds, but there can be negative effects. The most common of these is barotrauma—discomfort in the ear when the pressure on the outside of the ear is  different than the pressure on the inside of the ear. This is similar to when you are flying in a plane or diving under water and your ears feel like they are plugged up.

Although quite rare, patients can develop a tension pneumothorax. Other important potential side effects include hypoglycemia and hypoglycemic seizures, oxygen toxicity with seizures, and vision changes that can persist for up to 6 weeks after treatment.

Some patients are claustrophobic and require sedation medicine before entering the chamber.

Timely intervention

HBOT should not be considered a last-resort wound treatment, although typically insurers require an adequate trial of other high-quality wound care interventions before granting authorization. It’s important to refer potential patients early so they can get treatment as soon as possible. Early referral can make a significant difference. For example, HBOT may help the patient avoid an amputation, which has been shown to reduce life expectancy for patients with diabetes.

A healing effect

HBOT can make a difference in wound healing and, in turn, a patient’s quality of life. Keep this option in mind and refer patients with wounds who may benefit from it for further evaluation. For more information about HBOT, visit the website for the Undersea and Hyperbaric Medical Society.  Also, see Patient education resources for hyperbaric oxygen therapy.

Debra Clair is a wound care and hyperbaric therapy provider at University Hospitals Wound Care and Hyperbaric Center in Streetsboro, Ohio.

Selected references

Cakmak T, Battal B, Kara K, et al. A case of tension pneumothorax during hyperbaric oxygen therapy in an earthquake survivor with crush injury complicated by ARDS (adult respiratory distress syndrome). Undersea Hyperb Med. 2015;42(1):9-13.

Kaur S, Pawar M, Banerjee N, Garg R. Evaluation of the efficacy of hyperbaric oxygen therapy in the management of chronic nonhealing ulcer and role of periwound transcutaneous oximetry as a predictor of wound healing response: randomized prospective controlled trial. J Anaesthesiol Clin Pharmacol. 2012;28(1):70-5.

Medicare.gov. Hyperbaric oxygen (HBO) therapy. n.d.

Weaver LK, ed. Hyperbaric Oxygen Therapy Indications13th ed. Undersea and Hyperbaric Medical Society. 2014.

Online Resources

B. http://hyperbaricoxygentherapy.com/patient-info

C. http://www.hopkinsmedicine.org/healthlibrary/test_procedures/neurological/hyperbaric_oxygen_therapy_for_wound_healing_

135,44/

D. http://www.kentri.org/woundcare/hyperbaric-oxygen-therapyfacts.cfm

E. http://www.hyperbariccentersoftexas.com/what-are-the-side-effects-of-hyperbaric-oxygen-therapy#KiA1CbKWYd050Jjk.99

F. https://www.youtube.com/watch?v=HeW1m3TiNHI

G. https://www.youtube.com/watch?v=mh5UveY4r-U

Medicare reimbursement for hyperbaric oxygen therapy

By Carrie Carls, BSN, RN, CWOCN, CHRN, and Sherry Clayton, RHIA

In an atmosphere of changing reimbursement, it’s important to understand indications and utilization guidelines for healthcare services. Otherwise, facilities won’t receive appropriate reimbursement for provided services. This article focuses on Medicare reimbursement for hyperbaric oxygen therapy (HBOT). (See What is hyperbaric oxygen therapy?)

Indications and documentation requirements

The Centers for Medicare & Medicaid Services (CMS) National Coverage Determination for HBOT lists covered conditions for HBOT, as do the individual Medicare Administrative Contractor’s (MAC) Local Coverage Determination policies and/or articles. (See Conditions for which CMS approves use of HBOT.) Providers should thoroughly review the indications and utilization guidelines to ensure coverage criteria are met for each clinical condition.

It’s important that the documentation in the patient’s medical record supports the medical necessity for HBOT. Reimbursement hinges on documenting all services performed. For example, diabetic wounds of the lower extremity will first require the assessment of the patient’s vascular status with correction of any problems found, optimization of nutritional status and glucose control, removal of nonviable tissue, appropriate offloading of the ulcer, treatment and resolution of infection, and maintenance of a clean, moist wound bed.

HBOT is indicated if all of the above have been done and the ulcer doesn’t show measurable signs of healing after 30 days of standard wound care.

Provider requirements

For HBOT to be reimbursed, a facility must ensure the provider supervising the treatment meets CMS requirements. Physicians who supervise HBOT should be certified in Undersea and Hyperbaric Medicine or must have completed a 40-hour, in-person training program by an approved entity. In addition, if HBOT is performed off-site from a hospital campus or in a physician’s office, Advanced Cardiac Life Support training and certification of the supervising physician are required.

CMS also requires appropriate direct physician supervision for coverage, meaning that the physician must be present on the premises and immediately available to furnish assistance and direction throughout the performance of the procedure.

Billing and coding

In a hospital outpatient setting, the correct code is C1300, hyperbaric oxygen under pressure, full body chamber, per 30-minute interval. Physician supervision of HBOT is reported with CPT code 99183, physician attendance and supervision of hyperbaric oxygen therapy, per session. It’s important to note that the physician supervision code should be reported in a unit of 1, and the hospital outpatient procedure code of C1300 will be in multiple units, typically 4 units.

Prepay probes

Providers may be asked to submit medical documentation for specific claims identified by the MAC prior to payment (“prepay probes”). These Additional Development Requests require a response within 30 days and generally involve 20 to 40 claims per provider. Such requests occur in both inpatient and outpatient settings, and some MACs are starting to use prepay probes in skilled nursing facilities as well.

After review of the documentation, providers receive notification of the results. Further reviews are based on the provider error rate calculated.

Skilled nursing facility, inpatients, critical access hospitals

In a skilled nursing facility, HBOT is part of the facility Prospective Payment System (PPS) payment in Medicare part A stays. For hospital inpatients, HBOT is reported under revenue code 940. For critical access hospitals, a reasonable cost-based system is used.

Ensuring reimbursement

To ensure reimbursement of HBOT, check CMS policies and articles for indications, utilization guidelines, and provider requirements. In addition, ensure that documentation clearly supports the need for HBOT and follows the billing and coding requirements.

Both authors work at Passavant Area Hospital in Jacksonville, Illinois. Carrie Carls is the nursing director of advanced wound healing and hyperbaric medicine and Sherry Clayton is the director of managed care and revenue integrity.

Selected references
Centers for Medicare & Medicaid Services. Hyperbaric oxygen therapy (HBO) supplemental article (A52118). http://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52118. Accessed February 19, 2014.

Centers for Medicare & Medicaid Services. National coverage decision for hyperbaric oxygen therapy (20.29). Publication No. 100-3. http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx. Accessed February 19, 2014.

Clarke D. Economics of hyperbaric medicine. In: Kindwall E, Whelan H, eds. Hyperbaric Medicine Practice. 3rd ed. Flagstaff, AZ: Best Publishing Company; 2008;275-288.

Gesell L. Hyperbaric Oxygen Therapy Indications. 12th ed. Durham, NC: Undersea and Hyperbaric Medical Society; 2008.

Kranke P, Bennett MH, Roecki-Wiedmann I, Debus S. Hyperbaric oxygen for chronic wounds. Cochrane Database Syst Rev. http://www.ncbi.nlm.nih.gov/pubmed/22513920. Updated 2012. Accessed February 19, 2014.

National Government Services. Article for hyperbaric oxygen (HBO) therapy—medical policy (A52174). http://www.ngsmedicare.com. Accessed February 19, 2014.

National Government Services. Part B medical review: the medical review process. http://www.ngsmedicare.com. Accessed February 19, 2014.

Schaum K. Hyperbaric oxygen therapy reimbursement reminders for a successful 2010. Today’s Wound Clinic. 2010;4:9-14.

Tuner T. The coming audit storm. Today’s Wound Clinic. 2012;6:18-20, 38.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.