While teaching across the country at many wound care seminars in 2015 and 2016, I asked the attendees if they were preparing for the Centers for Medicare & Medicaid Services' (CMS's) Non-emergent Hyperbaric Oxygen Therapy (HBOT) Prior Authorization Model. Many of the attendees responded by saying that "Medicare does not provide prior authorization." Many others had not heard about this model. Some attendees heard about it, but did not pay any attention to it because "it does not affect them."
The only attendees who could relate to my HBOT Prior Authorization preparation question were those who work in Illinois, Michigan, and New Jersey, the 3 states participating in Medicare's 3-year HBOT Prior Authorization Model that began in 2015. The wound care professionals participating in the Prior Authorization Model strongly encouraged their fellow wound care professionals in other states to begin preparing now for HBOT Prior Authorization by Medicare, especially for the meticulous documentation and the selection of very specific diagnosis codes that are required.
Many attendees asked, "Why did CMS choose to test prior authorization on HBOT for certain covered conditions?" I shared CMS's answer to that question: "Previous experience indicates that HBOT has a high potential for improper payments and raises concerns about beneficiaries receiving medically unnecessary care. In the calendar year 2000, an Office of Inspector General Report on hyperbaric oxygen therapy found that
* $14.2 million (of the $49.9 million allowed charges for outpatient hospitals and physicians) was paid in error-beneficiaries received treatments for either noncovered conditions or documentation that did not adequately support hyperbaric oxygen therapy;
* an additional $4.9 million was paid for treatments deemed to be excessive; and
* lack of testing and treatment monitoring raise quality-of-care concerns."
When the attendees also asked why CMS chose the 3 states, I shared the reason that CMS provided: "Illinois, Michigan, and New Jersey were selected for initial implementation of this model because of their high utilization and improper payment rates. Beneficiaries in these states had the highest average sessions by total expenditures."
Each time I witnessed this discussion, I could not help but reflect on the many wound care professionals who did not use the time allotted to prepare for implementation of International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). That preparation also required meticulous clinical documentation improvement. When I reviewed the results of a nationwide survey conducted after the implementation of ICD-10-CM, a majority of wound care professionals reported they "wished they had taken the time (throughout the years allotted for ICD-10-CM preparation) to learn the specificity of the ICD-10-CM codes pertinent to their work and to improve their documentation one disease state at a time." Nearly everyone mentioned the necessity of knowing the exact descriptions of the ICD-10-CM codes and of breaking their old documentation habits and forming new documentation habits, which takes time and effort.
In last month's Payment Strategies column, we discussed the importance of learning the Surgical Dressing Local Coverage Determination (LCD) and the attached Article, and of thoroughly documenting the medical necessity for specific surgical dressings. When wound care professionals do not do their job properly, their patients incur costs that rightfully would be paid by their Medicare Part B insurance, if only their medical record justified the medical necessity for the surgical dressings that they need to change at home.
Qualified healthcare professionals (QHPs [physician, doctor of osteopathy, doctor of podiatric medicine, nurse practitioner, physician assistant, and clinical nurse specialist]) often tell me, "It is not my job to read medical policies," and minimize the importance of thorough documentation. In fact, some QHPs do not carefully review pertinent Medicare National Coverage Determinations (NCDs), LCDs, and Articles to understand the (1) indications/limitations surrounding the services, procedures, and/or products they use in their practices; (2) specific primary and secondary diagnosis codes that are covered; (3) utilization guidelines; and (4) documentation guidelines. This author recommends that wound care professionals assume personal responsibility for reviewing all Medicare NCDs, LCDs, and Articles that pertain to the work they perform. These documents are the wound care and hyperbaric oxygen therapy professionals' "playbook for success."
The CMS has published the HBOT NCD: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=12.
On June 3, 2016, CMS also released a change request that updated the specific list of diagnoses covered for HBOT: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R167. The change request provides a link (http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/CR9631.zip) to 12 spreadsheets-one of them is the spreadsheet of the covered diagnoses for HBOT. Please note that some diagnosis codes must be reported alone, and other diagnosis codes must be reported in pairs.
In addition to the CMS NCD, 50% of the Medicare Administrative Contractors (MACs) have released an HBOT LCD and/or Article (Table). If you work in a facility that performs HBOT, it is imperative that you read the CMS NCD and list of covered diagnosis codes, as well as your MAC's LCD and/or Article. If your MAC does not have an LCD/Article pertaining to HBOT, you may find it helpful to read the LCDs/Articles from 2 of the MACs participating in the Non-emergent HBOT Prior Authorization Model: National Government Services, Inc (in Illinois), and Novitas Solutions, Inc (in New Jersey). Note: As shown in the Table, Wisconsin Physicians Service Insurance Corporation has not released an HBOT LCD or Article.
Now let us focus on CMS's Prior Authorization of Non-emergent HBOT Process. The HBOT Prior Authorization is a process through which a hospital outpatient facility (type of bill 13) requests provisional affirmation of coverage (1) before HBOT services are furnished to a beneficiary and (2) before a claim is submitted for payment. The Prior Authorization of Non-emergent HBOT Process is not required by physicians who supervise HBOT. However, if a hospital outpatient facility has no prior authorization or a nonaffirmed prior authorization, the associated physician's claim will be subject to medical review. Critical access hospitals are also not included in this model and should not request prior authorization for HBOT.
Under HBOT Prior Authorization, the MACs make every effort to postmark their decisions within 10 business days for an initial request and within 20 business days for a resubmitted request (a request resubmitted with additional documentation after the initial prior authorization request was nonaffirmed). Prior authorization should be requested as soon as the hyperbaric oxygen therapy is scheduled. Treatment should not be delayed because of a pending prior authorization decision. However, claims should not be submitted until the prior authorization decision has been received from the MAC. Note: When the standard prior authorization decision timeframe could jeopardize the life or health of the beneficiary, the MAC will make reasonable efforts to communicate a decision within 2 business days.
Hospital outpatient facilities can receive prior authorization for up to 40 HBOT treatment sessions (G0277) in 12 months. Prior authorization affirmations will apply retroactively to the start date listed on the prior authorization request. Note: If additional sessions are needed in excess of the 40 treatments, a new prior authorization may be submitted.
Prior authorization helps ensure that applicable coverage, payment, and coding rules are met before services are rendered. The process is meant to reduce use of services that do not comply with Medicare policy while maintaining or improving quality of care. In most circumstances, a claim that has received prior authorization will not be stopped for prepayment review. However, CMS contractors, including Zone Program Integrity Contractors and MACs, may conduct targeted prepayment and postpayment reviews to ensure that claims are accompanied by documentation not required during the prior authorization process. In addition, the Comprehensive Error Rate Testing Contractor must review a random sample of claims for postpayment review.
Currently, 5 conditions require prior authorization in the 3 states participating in the Non-emergent HBOT Prior Authorization Model:
1. chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management;
2. osteoradionecrosis as an adjunct to conventional treatment;
3. soft tissue radionecrosis as an adjunct to conventional treatment;
4. actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment; and
5. diabetic wounds of the lower extremities in patients who meet the following 3 criteria:
* patient has type 1 or type 2 diabetes and has a lower-extremity wound that is due to diabetes;
* patient has a wound classified as Wagner grade 3 or higher; and
* patient has failed an adequate course of wound therapy as defined in the NCD
As described, wound care professionals in Illinois, Michigan, and New Jersey who are participating in the Non-emergent HBOT Prior Authorization Model strongly urged their peers in other states to focus on improving their documentation now before CMS implements prior authorization in their states. Remember that HBOT Prior Authorization does not create new documentation requirements. Instead, it enforces the NCD and LCD/Article requirements that are already in place. The participating wound care professionals also advised their peers that it is critical to obtain supporting documentation from referring practitioners (physicians and/or podiatrists) if they (1) performed standard wound care and/or (2) ordered and completed diagnostics before the patient presented to the hospital outpatient facility. This work and test results must be included in the Medicare beneficiary's medical record as supporting documentation for HBOT and must be supplied to the MAC in the HBOT Prior Authorization request.
The following is a list of the general documentation that your peers in Illinois, New Jersey, and Michigan must include with their HBOT Prior Authorization request from their MACs, if applicable based on the HBOT-covered indication. As you review the list, ask yourself if your HBOT medical records contain this documentation when required:
* HBOT history and physical
* HBOT physician order
* prior medical, surgical, and/or previous HBOT
* prior antibiotic therapy and surgical interventions or any adjunctive treatment being rendered
* laboratory reports (culture or Gram stains) confirming the diagnosis of actinomycosis
* X-ray findings and/or bone cultures confirming the diagnosis of chronic refractory osteomyelitis and what forms of medical and surgical management were tried and failed
* legible signed physician order for the service(s) billed
* procedure notes
* procedure logs-including ascent time, descent time, and pressurization level
Now ask yourself if your HBOT medical records contain other relevant documentation that the MACs require to determine the medical necessity and to process the prior authorization request for specific indications:
* Documentation for ActinomycosisNote: The HBOT is covered only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment.
[white circle] Identify the location of the infection
[white circle] Support the diagnosis of actinomycosis with a report of a diagnostic procedure: for example, the results of sputum, pus, or biopsy specimen cultures and so on
[white circle] Support the surgical incision and drainage of lesions
[white circle] Identify the prolonged administration of appropriate antibiotics
[white circle] Identify the conventional treatment/therapy the patient is receiving
* Documentation for Chronic Refractory Osteomyelitis
[white circle] Support an initial diagnosis of osteomyelitis with a report of a diagnostic procedure: for example, computed tomography (CT), magnetic resonance imaging (MRI), bone scan, and so on
[white circle] Identify the conventional medical management to which the patient did not respond
[white circle] Identify the conventional surgical management to which the patient did not respond
* Documentation for Diabetic Wounds of Lower Extremities
[white circle] Assess patient's vascular status and correction of vascular problems, if possible
[white circle] Support optimization of nutritional status
[white circle] Support optimization of glucose control
[white circle] Debridement to remove devitalized tissue
[white circle] Identify wound care management that includes maintenance of a clean, moist bed of granulated tissue with appropriate moist dressing
[white circle] Identify appropriate off-loading
[white circle] Identify treatment to resolve any infections
[white circle] Document no measurable signs of healing for at least 30 consecutive days of standard wound care prior to initiating HBOT
[white circle] Document measurable signs of healing for a patient currently receiving HBOT treatment for more than 30 days
* Documentation for OsteoradionecrosisNote: HBOT is covered only as an adjunct to conventional therapy
[white circle] Identify the location, the reason, the dates the treatment was received, and the strength of the radiation
[white circle] Support the diagnosis of osteoradionecrosis with report of a diagnostic procedure (eg, CT scan, MRI, or X-ray)
[white circle] Identify the conventional treatment/therapy the patient is receiving
* Documentation for Soft Tissue Radionecrosis
[white circle] Identify the location, the reason, the dates the treatment was received, and the strength of the radiation
[white circle] Support the diagnosis of soft tissue radionecrosis with a report of a diagnostic procedure. (eg, CT scan, visual examination, or biopsy)
[white circle] Identify the conventional treatment/therapy the patient is receiving.
Summary
When the Non-emergent HBOT Prior Authorization Model was implemented, the documentation (to support medical necessity and to process a prior authorization) deemed necessary by the MACs caught many wound care QHPs woefully unprepared. To ensure that patients who qualify for HBOT have access to the therapy, it is vitally important that all documentation required by CMS and the MACs be included with the request for prior authorization. For those facilities not currently under CMS HBOT Prior Authorization, now is the time to ensure that systems and processes are in place to capture and document all elements necessary to support the medical necessity of HBOT services. It is not unrealistic to assume that other MACs and private payers will implement the documentation requirements currently in place for the CMS HBOT Prior Authorization Model. It is also not unrealistic to assume that CMS will implement the Non-emergent HBOT Prior Authorization Model in additional states and possibly throughout the entire country.
Now that your interest about the Non-emergent HBOT Prior Authorization Model is piqued, visit http://go.cms.gov/PAHBO for more information.