CMS does not believe the Colon is a soft tissue so using the description of Soft Tissue Radio necrosis of the bowel, colon, anus would be a hard stop for CMS. Many subject matter experts in the hyperbaric community have contested the misinterpretation/mis classification of the words soft tissue with CMS. CMS is adamant that the bowel is not a soft tissue. It is a battle that the hyperbaric committee has lost with CMS.

As such the actual HBO treatment of Radiation injury to the bowel in some studishas shown clinical effectives has high as 76% in that some improvement to complete resolution.
To be clear when documenting on a patient with delayed effect of radiation to the bowel, one should never use soft tissue radionecrosis any where in its description. Having a comprehensive document , Quality of life discussion and clear discussion of all symptoms related to delayed of radiation and how it can impact the quality of life is the best way to protect the patient as well as the medical record from third party review. What I cant predict at any time is what will a third party reviewer do when reviewing an individual chart. I have had success after CMS review of my patients that have had delayed of radiation to the bowel ( with no mention of soft tissue radionecrosis). Most importantly meticulous documentation and discussion of improvement of QOL indications. As a disclaimer one can never predict how a third party reviewer will evaluate your medical record

Mitch, Thank you for reaching out! This is a great question. In a Guest Post by Dr. Helen Gelly: "Medicare Denials for Radiation Proctitis" by Caroline Fife, M.D. | Nov 12, 2020 Dr. Gelly discusses this very topic, the following are excerpts from her post: Why are Medicare charges for hyperbaric oxygen therapy (HBOT) denied when treating radiation proctitis? National Coverage Decision (NCD) 20.29 (Hyperbaric Oxygen Therapy) supports Medicare coverage of radiation-induced injury in the pelvis under the definition of soft tissue radiation necrosis. However, Medicare may deny charges for HBOT in the treatment of radiation proctitis unless the diagnosis of soft tissue radionecrosis is also linked and precedes it. Radiation to the pelvis involves two main areas, bladder and rectum. Radiation damage to the bladder has an assigned CPT code in the code list approved by Medicare for HBOT. The code for Radiation proctitis (ICD-10-CM K62.7) is NOT on the list of approved codes for HBOT. Although commercial carriers uniformly cover this indication and the American Society of Colon and Rectal Surgeons has listed hyperbaric oxygen therapy as an accepted therapeutic modality in the treatment of radiation proctitis, Medicare may not cover it, depending upon the coding. If radiation damage to the bladder is covered, why not to the bowel?

Part of the problem is that bowel is not considered “soft tissue” according to the medical definition of soft tissue which includes muscle, fat, fascia, tendon, ligaments, etc. It is perhaps unfortunate that the Undersea and Hyperbaric Medical Society (UHMS) identified all tissues that are not bone (hard) as “soft” when crafting statements about the effectiveness of HBOT in this condition. While bowel would seem to be a “soft tissue” (since it is not bone), CMS still uses the literal meaning of soft tissue as a potential reason to deny HBOT.

To have a hope of payment, the physician must document if possible, fibrosis of the anterior abdominal wall. If the patient had external beam radiation, then fibrosis may be evident on the abdominal wall. The physician should ask very specific questions about urinary symptoms since radiation damage might have affected the bladder. The problem is that patients focus on the problems which concern them the most and if their most life altering problem is radiation proctitis, they might fail to mention radiation cystitis. CMS covers radiation cystitis without hematuria, so be sure to ask about bladder symptoms. If present along with radiation proctitis, it would be best to code the condition as radiation cystitis (N30.4X). Remember that K52.0 (Gastroenteritis and colitis due to radiation) and K62.7 ( radiation proctitis) have never been listed codes.

The following links might be useful in establishing the “standard of care” for radiation proctitis when you appeal:
(1) https://www.ncbi.nlm.nih.gov/books/NBK537343/
(2) https://www.sciencedirect.com/topics/medicine-and-dentistry/radiation-proctitis

I hope this helps. Please let us know if you have any additional thoughts.
Have a great day!
Jeff

Thank you all for your feedback. It is greatly appreciated.

Mitch

Mitch,

David and Jeff at totally correct about the state of affairs with CMS and radiation proctitis. And as David noted, the documentation in the HBO physical should be more geared to symptoms a rather than location.