L28887

 

HYPERBARIC OXYGEN THERAPY (HBO THERAPY)

 

01/01/2013

 

Indications and Limitations of Coverage and/or Medical Necessity

Indications:

• In order to receive Medicare reimbursement for HBO therapy, services must be rendered under the direct supervision of the physician.

HBO therapy is covered by Medicare for the following conditions:

• Acute carbon monoxide intoxication induces hypoxic stress.

o The cardiac and central nervous systems are the most susceptible to injury from carbon monoxide. The administration of supplemental oxygen is essential treatment.

o Hyperbaric oxygen causes a higher rate of dissociation of carbon monoxide from hemoglobin than can occur breathing pure air at sea level pressure.

o The chamber compressions should be between 2.5 and 3.0 atm abs.

o It is not uncommon in patients with persistent neurological dysfunction to require subsequent treatments within six to eight hours, continuing once or twice daily until there is no further improvement in cognitive functioning.

• Decompression illness arises from the formation of gas bubbles in tissue or blood in volumes sufficient enough to interfere with the function of an organ or to cause alteration in sensation.

o The cause of this enucleated gas is rapid decompression during ascent.

o The clinical manifestations range from skin eruptions to shock and death.

o The circulating gas emboli may be heard with a Doppler device.

o Treatment of choice for decompression illness is HBO with mixed gases.

o The result is immediate reduction in the volume of bubbles.

o The treatment prescription is highly variable and case specific.

o The depths could range between 60 to 165 feet of sea water for durations of 1.5 to over 14 hours. The patient may or may not require repeat dives.

• Gas embolism occurs when gases enter the venous or arterial vasculature embolizing in a large enough volume to compromise the function of an organ or body part.

o This occlusive process results in ischemia to the affected areas.

o Air emboli may occur as a result of

 Surgical procedures (e.g., cardiovascular surgery, intra-aortic balloons, arthroplasties, or endoscopies),

 Use of monitoring devices (e.g., Swan-Ganz introducer, infusion pumps),

 in nonsurgical patients (e.g., diving, ruptured lung in respirator-dependent patient, injection of fluids into tissue space), or

 Traumatic injuries (e.g., gunshot wounds, penetrating chest injuries).

o Hyperbaric oxygen therapy is the treatment of choice.

o It is most effective when initiated early.

o Therapy is directed toward reducing the volume of gas bubbles and increasing the diffusion gradient of the embolized gas.

o Treatment modalities range from high pressure to low pressure mixed gas dives.

• Gas gangrene is an infection caused by the clostridium bacillus, the most common being clostridium perfringens.

o Clostridial myositis and myonecrosis (gas gangrene) is an acute, rapidly growing invasive infection of the muscle.

 It is characterized by profound toxemia, extensive edema, massive death of tissue and variable degree of gas production.

 The most prevalent toxin is the alpha-toxin which in itself is hemolytic, tissue-necrotizing and lethal.

 The diagnosis of gas gangrene is based on clinical data supported by a positive gram-stained smear obtained from tissue fluids.

 X-ray radiographs, if obtained, can visualize tissue gas.

o The onset of gangrene can occur one to six hours after injury and presents with severe and sudden pain at the infected area.

 The skin overlying the wound progresses from shiny and tense, to dusky, then bronze in color. The infection can progress as rapidly as six inches per hour.

 Hemorrhagic vesicles may be noted.

 A thin, sweet-odored exudate is present. Swelling and edema occur.

 The noncontractile muscles progress to dark red to black in color.

o The acute problem in gas gangrene is to stop the rapidly advancing infection caused by alpha-toxin.

 Medical treatment is aimed at stopping the production of alpha-toxin and to continue treatment until the advancement of the disease process has been arrested.

 The goal of HBO therapy is to stop alpha-toxin production thereby inhibiting further bacterial growth at which point the body can use its own host defense mechanisms.

 HBO treatment starts as soon as the clinical picture presents and is supported by a positive gram-stained smear.

 A treatment approach utilizing HBO is adjunct to antibiotic therapy and surgery. Initial surgery may be limited to opening the wound.

 Debridement of necrotic tissue can be performed between HBO treatments when clear demarcation between dead and viable tissue is evident.

 The usual treatment consists of oxygen administered at 3.0 atm abs pressure for 90 minutes three times in the first 24 hours.

 Over the next four to five days, treatment sessions twice a day are usual.

 The sooner HBO treatment is initiated, the better the outcome in terms of life, limb and tissue saving.

• Crush injuries and suturing of severed limbs, acute traumatic peripheral ischemia (ATI), and acute peripheral arterial insufficiency associated with arterial embolism and thrombosis:

o Acute traumatic ischemia is the result of injury by external force or violence compromising circulation to an extremity.

o The extremity is then at risk for necrosis or amputation.

o Secondary complications are frequently seen: infection, non-healing wounds, and non-united fractures.

o The goal of HBO therapy is to enhance oxygen at the tissue level to support viability.

 When tissue oxygen tensions fall below 30mm Hg, the body’s ability to respond to infection and wound repair is compromised.

 Using HBO at 2-2.4 atm, the tissue oxygen tension is raised to a level such that the body’s responses can become functional again.

 The benefits of HBO therapy for this indication are enhanced tissue oxygenation, edema reduction and increased oxygen delivery per unit of blood flow thereby reducing the complication rates for infection, nonunion and amputation.

o The usual treatment schedule is three 1.5 hour treatment periods daily for the first 48 hours.

 Additionally, two 1.5 hour treatment sessions daily for the next 48 hours may be required.

 On the fifth and sixth days of treatment, one 1.5 hour session would typically be utilized.

 At this point in treatment, outcomes of restored perfusion, edema reduction and either demarcation or recovery would be sufficient to guide discontinuing further treatments.

o For acute traumatic peripheral ischemia, crush injuries and suturing of severed limbs,

 Hyperbaric Oxygen 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.

 Arterial insufficiency ulcers may be treated by HBO therapy if they are persistent after reconstructive surgery has restored large vessel function.

• The principal treatment for progressive necrotizing infections (necrotizing fasciitis) is surgical debridement and systemic antibiotics.

o HBO therapy is recommended as an adjunct only in those settings where mortality and morbidity are expected to be high despite aggressive standard treatment.

o Progressive necrotizing fasciitis is a relatively rare infection.

o It is usually a result of a group-A streptococcal infection beginning with severe or extensive cellulitis that spreads to involve the superficial and deep fascia, producing thrombosis of the subcutaneous vessels and gangrene of the underlying tissues.

o A cutaneous lesion usually serves as a portal of entry for the infection, but sometimes no such lesion is found.

• Preparation and preservation of compromised skin grafts utilizes HBO therapy for graft or flap salvage in cases where hypoxia or decreased perfusion has compromised viability.

o This indication is not for primary management of wounds.

o HBO therapy enhances flap survival.

o Treatments are given at a pressure of 2.0 to 2.5 atm abs lasting from 90-120 minutes. It is not unusual to receive treatments twice a day.

o When the graft or flap appears stable, treatments are reduced to daily.

o Should a graft or flap fail, HBO therapy may be used to prepare the already compromised recipient site for a new graft or flap.

o It does not apply to the initial preparation of the body site for a graft. HBO therapy is not necessary for normal, uncompromised skin grafts or flaps.

o Medicare’s coverage does not apply to artificial skin grafts.

• Chronic refractory osteomyelitis persists or recurs following appropriate interventions.

o These interventions include the use of antibiotics, aspiration of the abscess, immobilization of the affected extremity, and surgery.

o HBO therapy is an adjunctive therapy used with the appropriate antibiotics.

o Antibiotics are chosen on the basis of bone culture and sensitivity studies.

o HBO therapy can elevate the oxygen tensions found in infected bone to normal or above normal levels.

o This mechanism enhances healing and the body’s antimicrobial defenses.

o It is believed that HBO therapy augments the efficacy of certain antibiotics (gentamicin, tobramycin, and amikacin).

o Finally, the body’s osteoclast function of removing necrotic bone is dependent on a proper oxygen tension environment.

o HBO therapy provides this environment.

o HBO treatments are delivered at a pressure of 2.0 to 2.5 atm abs for a duration of 90-120 minutes.

o It is not unusual to receive daily treatments following major debridement surgery.

o The number of treatments required varies on an individual basis.

o Medicare can cover the use of HBO therapy for chronic refractory osteomyelitis that has been demonstrated to be unresponsive to conventional medical and surgical management.

• HBO’s use in the treatment of osteoradionecrosis and soft tissue radionecrosis is one part of an overall plan of care.

o Also included in this plan of care are debridement or resection of nonviable tissue in conjunction with antibiotic therapy.

o Soft tissue flap reconstruction and bone grafting may also be indicated. HBO treatment can be indicated both preoperatively and postoperatively.

o HBO therapy must be utilized as an adjunct to conventional therapy.

o The patients who suffer from soft tissue damage or bone necrosis present with disabling, progressive, painful tissue breakdown.

 They may present with wound dehiscence, infection, tissue loss and graft or flap loss.

 The goal of HBO treatment is to increase the oxygen tension in both hypoxic bone and tissue to stimulate growth in functioning capillaries, fibroblastic proliferation and collagen synthesis.

 The recommended daily treatments last 90-120 minutes at 2.0 to 2.5 atm abs. The duration of HBO therapy is highly individualized.

• Cyanide poisoning carries a high risk of mortality.

o Victims of smoke inhalation frequently suffer from both carbon monoxide and cyanide poisoning.

o The traditional antidote for cyanide poisoning is the infusion of sodium nitrite.

o This treatment can potentially impair the oxygen carrying capacity of hemoglobin.

o Using HBO therapy as an adjunct therapy adds the benefit of increased plasma dissolved oxygen.

o HBO’s benefit for the pulmonary injury related to smoke inhalation remains experimental.

o The HBO treatment protocol is to administer oxygen at 2.5 to 3.0 atm abs for up to 120 minutes during the initial treatment.

o Most patients with combination cyanide and carbon monoxide poisoning will receive only one treatment.

• Actinomycosis is a bacterial infection caused by Actinomyces israelii.

o Its symptoms include slow growing granulomas that later breakdown, discharging viscid pus containing minute yellowish granules.

o The treatment includes prolonged administration of antibiotics (penicillin and tetracycline). Surgical incision and draining of accessible lesions is also helpful.

o Only after the disease process has shown refractory to antibiotics and surgery, could HBO therapy be covered by Medicare.

 HBO therapy must be utilized adjunct to conventional therapy.

• Treatment of diabetic wounds of the lower extremities in patients who meet the following criteria:

o Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes.

o Patient has a wound classified as Wagner grade III or higher (Grade 3 – Osteitis, abscess, or osteomyelitis, Grade 4 – Gangrene of the forefoot, Grade 5 – Gangrene of the entire foot); and

o Patient has failed an adequate course of standard wound therapy.

• The use of HBO therapy will be 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:

o Assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible.

o Optimization of nutritional status.

o Optimization of glucose control.

o Debridement by any means to remove devitalized tissue.

o Maintenance of clean, moist bed of granulation tissue with appropriate moist dressings.

o Appropriate off-loading.

o 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.

o Wounds must be evaluated at least every 30 days during administration of HBO therapy.

o Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.

• Prior to the initiation of HBO therapy, it is expected in most cases that the diagnosis will be established by the referring or treating physician.

• Indications of effective treatment outcomes for HBO include:

o Improvement or healing of wounds.

o Improvement of tissue perfusion.

o New epithelial tissue growth and granulation.

o Tissue PO2 of at least 30 mmHg of oxygen is necessary for oxidative function to occur.

o Mechanical reduction in the bubble size of air emboli alleviates decompression sickness and gas/ air emboli.

o Tissue PO2 of 40 or greater defines resolved hypoxia. The body can now resume host functions of wound healing and anti-microbial defenses without the need of HBO therapy.

Limitations:

• HBO therapy should not be a replacement for other standard successful therapeutic measures; however, it is the treatment of choice and standard of care for decompression sickness and arterial gas embolism.

• Traumatic or spontaneous pneumothorax constitutes contraindications to adjunctive HBO therapy only if untreated.

o Pregnancy is considered a contraindication to HBO therapy except in the case of carbon monoxide poisoning where it is specifically indicated.

• Topical application of oxygen (Topox) does not meet the definition of HBO therapy for coverage under Medicare.

o Also, its clinical efficacy has not been established; therefore, no reimbursement may be made for the topical application of oxygen.

• No program payment may be made for HBO in the treatment of the following conditions:

o Cutaneous, decubitus and stasis ulcers.

o Chronic peripheral vascular insufficiency.

o Anaerobic septicemia and infection other than clostridia.

o Skin burns (thermal)

o Senility.

o Myocardial infarction.

o Cardiogenic shock.

o Sickle cell anemia.

o Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency.

o Acute or chronic cerebral vascular insufficiency.

o Hepatic necrosis.

o Aerobic septicemia.

o Nonvascular causes of chronic brain syndrome (Pick’s disease, Alzheimer’s disease, Korsakoff’s disease).

o Tetanus.

o Systemic aerobic infection.

o Organ transplantation.

o Organ storage.

o Pulmonary emphysema.

o Exceptional blood loss anemia.

o Multiple sclerosis.

o Arthritic diseases.

o Acute cerebral edema.

Coding Information

 

Bill Type Codes

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

13x Hospital Outpatient

85x Critical Access Hospital

 

Revenue Codes

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

0413 Respiratory Services - Hyperbaric Oxygen Therapy

0940 Other Therapeutic Services - General Classification

 

 

CPT/HCPCS Codes

 

99183 PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL ATTENDANCE AND SUPERVISION OF HYPERBARIC OXYGEN THERAPY, PER SESSION

 

 

ICD-9 Codes that Support Medical Necessity

 

039.0 CUTANEOUS ACTINOMYCOTIC INFECTION

039.1 PULMONARY ACTINOMYCOTIC INFECTION

039.2 ABDOMINAL ACTINOMYCOTIC INFECTION

039.3 CERVICOFACIAL ACTINOMYCOTIC INFECTION

039.4 MADURA FOOT

039.8 ACTINOMYCOTIC INFECTION OF OTHER SPECIFIED SITES

039.9 ACTINOMYCOTIC INFECTION OF UNSPECIFIED SITE

040.0 GAS GANGRENE

250.70 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.71 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.72 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.73 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.80 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.81 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.82 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.83* DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

444.21 ARTERIAL EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY

444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY

444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY

526.89 OTHER SPECIFIED DISEASES OF THE JAWS

707.10* UNSPECIFIED ULCER OF LOWER LIMB

707.12* ULCER OF CALF

707.13* ULCER OF ANKLE

707.14* ULCER OF HEEL AND MIDFOOT

707.15* ULCER OF OTHER PART OF FOOT

707.19* ULCER OF OTHER PART OF LOWER LIMB

728.86 NECROTIZING FASCIITIS

730.10 CHRONIC OSTEOMYELITIS SITE UNSPECIFIED

730.11 CHRONIC OSTEOMYELITIS INVOLVING SHOULDER REGION

730.12 CHRONIC OSTEOMYELITIS INVOLVING UPPER ARM

730.13 CHRONIC OSTEOMYELITIS INVOLVING FOREARM

730.14 CHRONIC OSTEOMYELITIS INVOLVING HAND

730.15 CHRONIC OSTEOMYELITIS INVOLVING PELVIC REGION AND THIGH

730.16 CHRONIC OSTEOMYELITIS INVOLVING LOWER LEG

730.17 CHRONIC OSTEOMYELITIS INVOLVING ANKLE AND FOOT

730.18 CHRONIC OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES

730.19 CHRONIC OSTEOMYELITIS INVOLVING MULTIPLE SITES

902.53 INJURY TO ILIAC ARTERY

903.01 INJURY TO AXILLARY ARTERY

903.1 INJURY TO BRACHIAL BLOOD VESSELS

904.0 INJURY TO COMMON FEMORAL ARTERY

904.41 INJURY TO POPLITEAL ARTERY

909.2 LATE EFFECT OF RADIATION

927.00 CRUSHING INJURY OF SHOULDER REGION

927.01 CRUSHING INJURY OF SCAPULAR REGION

927.02 CRUSHING INJURY OF AXILLARY REGION

927.03 CRUSHING INJURY OF UPPER ARM

927.09 CRUSHING INJURY OF MULTIPLE SITES OF UPPER ARM

927.10 CRUSHING INJURY OF FOREARM

927.11 CRUSHING INJURY OF ELBOW

927.20 CRUSHING INJURY OF HAND(S)

927.21 CRUSHING INJURY OF WRIST

927.8 CRUSHING INJURY OF MULTIPLE SITES OF UPPER LIMB

927.9 CRUSHING INJURY OF UNSPECIFIED SITE OF UPPER LIMB

928.00 CRUSHING INJURY OF THIGH

928.01 CRUSHING INJURY OF HIP

928.10 CRUSHING INJURY OF LOWER LEG

928.11 CRUSHING INJURY OF KNEE

928.20 CRUSHING INJURY OF FOOT

928.21 CRUSHING INJURY OF ANKLE

928.3 CRUSHING INJURY OF TOE(S)

928.8 CRUSHING INJURY OF MULTIPLE SITES OF LOWER LIMB

928.9 CRUSHING INJURY OF UNSPECIFIED SITE OF LOWER LIMB

929.0 CRUSHING INJURY OF MULTIPLE SITES NOT ELSEWHERE CLASSIFIED

929.9 CRUSHING INJURY OF UNSPECIFIED SITE

958.0 AIR EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA

986 TOXIC EFFECT OF CARBON MONOXIDE

987.7 TOXIC EFFECT OF HYDROCYANIC ACID GAS

989.0 TOXIC EFFECT OF HYDROCYANIC ACID AND CYANIDES

990 EFFECTS OF RADIATION UNSPECIFIED

993.2 OTHER AND UNSPECIFIED EFFECTS OF HIGH ALTITUDE

993.3 CAISSON DISEASE

996.52 MECHANICAL COMPLICATION OF PROSTHETIC GRAFT OF OTHER TISSUE NOT ELSEWHERE CLASSIFIED

996.90 COMPLICATIONS OF UNSPECIFIED REATTACHED EXTREMITY

996.91 COMPLICATIONS OF REATTACHED FOREARM

996.92 COMPLICATIONS OF REATTACHED HAND

996.93 COMPLICATIONS OF REATTACHED FINGER(S)

996.94 COMPLICATIONS OF REATTACHED UPPER EXTREMITY OTHER AND UNSPECIFIED

996.95 COMPLICATION OF REATTACHED FOOT AND TOE(S)

996.96 COMPLICATION OF REATTACHED LOWER EXTREMITY OTHER AND UNSPECIFIED

996.99 COMPLICATION OF OTHER SPECIFIED REATTACHED BODY PART

999.1 AIR EMBOLISM AS A COMPLICATION OF MEDICAL CARE NOT ELSEWHERE CLASSIFIED

* The billing of hyperbaric oxygen therapy for the treatment of diabetic wounds of the lower extremities requires dual diagnoses. To ensure reimbursement for this service, dual diagnoses must be submitted. An ICD-9-CM code from the 250.80-250.83 range (representing a diabetes-related problem) and one of the following ICD-9-CM codes: 707.10, 707.12, 707.13, 707.14, 707.15 or 707.19 (representing a lower extremity wound) must be reported.

 

 

Documentation Requirements

• There must be medical documentation to support the condition for which HBO therapy is being given.

o Documentation for all services should be maintained on file (e.g., progress notes and treatment record) to substantiate medical necessity for HBO treatment.

• This medical documentation must include:

o An initial assessment which will include a medical history detailing the condition requiring HBO therapy.

 The medical history should list prior treatments and their results including antibiotic therapy and surgical interventions.

 This assessment should also contain information about adjunctive treatment currently being rendered.

o Physician progress notes.

o Any communication between physicians detailing past or future (proposed) treatments.

o HBO treatment records describing the physical findings, the treatment rendered and the effect of the treatment upon the established goals for therapy.

o For conditions where HBO is covered when there is a threatened loss of function, limb, or life, the documentation must support this finding.

o For conditions where HBO is covered as an adjunctive treatment, the documentation should include information concerning all treatment modalities utilized.

o Positive gram-stain smear is required to support the diagnosis of gas gangrene.

o For patients treated for osteomyelitis, definitive radiographic findings or positive bone culture with sensitivity studies to confirm the diagnosis of osteomyelitis, and documentation of failed antibiotic therapy.

o For patients treated for osteoradionecrosis, history of radiation therapy (including date and anatomical site of radiation therapy), with evidence of necrotic bone tissue breakdown, and radiographic studies, if available, to confirm the diagnosis.

o For patients treated for soft tissue radionecrosis, history of radiation therapy and clinical photographs of the necrotic site will help support the medical necessity of HBO services.

o For treatment of diabetic wounds of the lower extremities, documentation must indicate that the patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; the patient has a wound classified as Wagner grade III or higher; the patient has failed an adequate course of standard therapy.

 Documentation must also reflect that there has been no measurable signs of healing for at least 30 days of treatment with standard wound therapy and that the HBO therapy has been used in addition to standard wound care with wound evaluation every 30 days during HBO therapy.

Utilization Guidelines

• Payment will be made for HBO therapy when it 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 2 to 4 weeks.

• The use of hyperbaric oxygen for more than 2 months, (30 days for the treatment of diabetic wounds) regardless of the condition of the patient, will be reviewed for medical necessity before further reimbursement is made.

 

 

Treatment Logic

• Hyperbaric Oxygen Therapy is a medical treatment in which the patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O2) at greater than one atmosphere (atm) pressure.

• Either a monoplace chamber pressurized with pure O2 or a larger multiplace chamber pressurized with compressed air where the patient receives pure O2 by mask, head tent, or endotracheal tube may be used.

 

Sources of Information and Basis for Decision

 

Dorland’s Illustrated Medical Dictionary, 28th edition. Philadelphia. W.B. Saunders Co.

 

Undersea and Hyperbaric Medical Society. Indications for Hyperbaric Oxygen Therapy. Retrieved from http://www.uhms.org/indications/referenc.htm.

 

FCSO LCD-29192 Title: Hyperbaric Oxygen Therapy (HBO Therapy), 01/01/2013. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

CMS LCD L28887 HYPERBARIC OXYGEN THERAPY (HBO THERAPY)