INTRODUCTION

Determining whether an Advanced Practice Provider (APP) can supervise hyperbaric oxygen therapy (HBOT) is not a simple process. Advanced Practice Provider is a general title used to describe individuals who have completed the advanced education and training that qualifies them to (1) manage medical problems and (2) prescribe and manage treatments within the scope of their training. APP's include Advanced Practice Nurses (APN) and Physician Assistants (PA).  Some specific types of APNs include nurse practitioners (NP), clinical nurse specialists (CNS), nurse anesthetists (CRNA), and nurse-midwives (CNM). Medicare uses the term "non-physician practitioner" to describe advanced practice nurses and physician assistants. 

All are providers of healthcare and may receive reimbursement from Medicare and other payers. These providers may obtain their own National Provider Identifier (NPI) which allows them to bill directly for their services at a discounted rate from that of the physician. Additionally, they may bill incident to the work of a physician with the physician’s patients. For example, they may carry out services under a treatment plan established by the physician such as a follow-up visit for a known diagnosis. [1] 

Nurse practitioners serve as primary and specialty care providers. The most common specialty areas for NP’s are family practice, adult practice, women’s health, pediatrics, acute care, and geriatrics. They may also prescribe certain medications.[1] 

For the purpose of this article, we will focus on the APN such as the nurse practitioner role in supervising HBOT. To understand if an NP may bill for HBOT, you must first start with these three questions:

1. Do the Centers for Medicare and Medicaid Services (CMS) allow it?
2. Does the NP's scope of practice within the state of practice allow it?
3. Does the institutional credentialing department allow it?

DOES CMS ALLOW IT? 

From a Federal Ruling Standpoint

CMS outlines in the Federal Register the supervision requirements for NP's in Provider-Based Departments or Hospital-based outpatient departments. NPs have been given the jurisdiction to supervise hospital outpatient therapeutic services; HBOT is considered a component of those services. 

• Because hospital outpatient therapeutic services are furnished incident to a physician’s/NPP's professional service, the conditions of payment that derive from the “incident to” nature of the services paid apply to all hospital outpatient therapeutic services. 
• Section 410.27 describes hospital or CAH services and supplies furnished incident to a physician’s or nonphysician practitioner’s services as therapeutic services and provides the conditions of payment. All services that aid the physician or NPP in the treatment of the patient, including drugs and biologicals that cannot be self-administered, if they are furnished under the direct supervision of a clinical psychologist, licensed clinical social worker, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife. [2] 

From the Medicare Administrative Contractors (MAC) Standpoint

MACs determine which types of interventions are covered along with documentation needed to justify medical necessity, utilization guidelines, frequency allowed, etc. Clinicians who bill Medicare should adhere to the guidance provided by their MAC to ensure proper reimbursement and smooth audits should they occur. To find out which MAC covers your state and respective coverage determinations, see topic "Medicare Coverage Determinations for Hyperbaric Oxygen Therapy".

Is there a Local Coverage Determination for Hyperbaric Oxygen Therapy?

The NP must consult their Coverage Determination for HBOT. If there is no specific LCD for hyperbaric oxygen therapy, then the National Coverage Determination 20.29 would apply, followed by the NP's state licensure scope and practice.[3] However, even if higher regulatory spheres allow NPs and PAs to supervise HBOT, the ultimate decision would lie with the institution, who grants clinical privileges.

Up until 8/27/20, Novitas and First Coast Service Options (FCSO) were the only MACs with LCDs pertaining to HBOT. However, based on review of the LCDs and billing and coding article for HBOT, it was determined that they are no longer required and therefore, were retired on 8/27/20. NCD 20.29 is in effect to replace those LCDs, so HBOT coverage is not expected to change in the states covered by Novitas and FCSO.

Of note, however, those LCDs previously in place differed from the NCD 20.29 as it relates to HBOT supervision. Also, unlike the NCD 20.29, the retired LCDs laid out specific guidance related to the ability for Advanced Practice Providers (e.g., nurse practitioners) to supervise HBOT services:

Supervision of HBOT by Advanced Practice Providers: unlike the NCD 20.29, the LCDs provided clarification that "Qualified Providers may supervise HBOT services, if such service including definitive evaluation of the patient is included within their State Scope of Practice, or if their required supervision or collaborative agreement is with a physician qualified to provide HBOT services who remains immediately available and if the provider meets the educational requirements identified herein". In practice, the status quo is not expected to change within the states covered by Novitas and FCSO, as the NCD does not provide guidance related to this matter. Supervision of HBOT by advanced practice providers is still subject to the provider's scope of practice within the state of practice, and the ultimate decision lies with each institution, which grants clinical privileges.

DOES THE NP's SCOPE OF PRACTICE WITHIN THE STATE OF PRACTICE ALLOW IT?  

NP Supervision Requirements

It is crucial that NPs have a clear understanding of how their state laws and regulations impact their scope of practice. NPs fall under the following scopes of practice environment depending on the state in which they practice: they may be able to work independently (full practice), with a reduced practice, or with a restricted practice.[4]  

• Both "reduced" and "restricted" practice require a "Collaborative Practice Agreement". The degree to which a physician needs to interface with the NP depends upon the collaborative agreement rules for that state. 
• Collaboration is defined as a process in which a NP works with a physician to deliver healthcare services within the scope of the practitioner’s professional expertise, with medical direction and appropriate supervision as provided for in jointly developed guidelines or other mechanisms as defined by the law of the State in which the services are performed. Citation: 42 U.S.C.S. § 1395x(aa)(6).
• The difference between "reduced" and "restricted" practice is the amount of oversight that is needed, as well as what an NP can or cannot do in their scope of practice. This is dictated by the state's board of registered nursing. An NP's scope of practice is broad and covers many activities, therefore the supervision of HBOT would not be specifically mentioned.
• In some states, although NP's may be allowed to supervise HBOT, they are not allowed to perform the consultation, write orders, set the protocol or manage new problems. They are allowed to manage existing problems under a protocol. For example, if the patient has new episode of ear pain, the NP cannot diagnose or treat the patient without the physician having first seen the patient. 

NPs Practice Environment

An overview of the three types of NP practice environments is described below [4]:

• Restricted state practice and licensure laws: restrict the ability of NPs to engage in at least one element of NP practice. State law requires career-long supervision, delegation or team management by another health provider in order for the NP to provide patient care.
• Reduced state practice and licensure laws: reduce the ability of NPs to engage in at least one element of NP practice. State law requires a career-long regulated collaborative agreement with another health provider in order for the NP to provide patient care, or it limits the setting of one or more elements of NP practice.
• Full state practice and licensure laws: permit all NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing. This is the model recommended by the National Academy of Medicine, formerly called the Institute of Medicine, and the National Council of State Boards of Nursing.

Restricted Practice States

Below are the "Restricted Practice" States (collaborative agreement with a physician required)[4]:

• California
• Florida
• Georgia
• Michigan
• Missouri
• North Carolina
• Oklahoma
• South Carolina
• Tennessee
• Texas
• Virginia

Reduced Practice States

Below are the "Reduced Practice" States (collaborative agreement with a physician required)[4]:

• Alabama
• American Samoa
• Arkansas
• Illinois
• Indiana
• Kentucky
• Louisiana
• Mississippi
• New Jersey
• Ohio
• Pennsylvania
• Puerto Rico
• Virgin Islands
• West Virginia
• Wisconsin

• Alaska
• Arizona
• Colorado
• Connecticut
• Delaware
• District of Columbia
• Guam
• Hawaii
• Idaho
• Iowa
• Kansas
• Maine
• Maryland
• Massachusetts
• Minnesota
• Montana
• Nebraska
• Nevada
• New Hampshire
  
• New Mexico
• New York
• North Dakota
  
• Northern Mariana Islands
• Oregon
• Rhode Island
• South Dakota
• Utah
• Vermont
• Washington
• Wyoming

The reader should refer to the state board of nursing in each state for the specific requirements.

DOES THE INSTITUTIONAL CREDENTIALING DEPARTMENT ALLOW IT? 

Credentialing and Privileging

An NP must request and be granted privileges from the institution just as a physician would. Medicare requires that providers be re-credentialed no less than every 3 years.[5]

What is credentialing?

What is privileging?

To understand credentialing and privileging, it is helpful to first look at the requirements and examine how laws, regulations, agency policies, and common law affect whether or not a nurse practitioner is able to practice in a specific setting and under what conditions. 

If an applicant is denied credentials and privileges or their privileges are limited, there are provisions in the bylaws that specify how to appeal the denial or limitation(s). It is important to remember that the burden is on the applicant to demonstrate that the denial or limitation is inappropriate, not on the credentialing/ executive committee to prove that this action was unwarranted.[5] 

UHMS POSITION STATEMENT

Regarding Advanced Practice Providers (APP) Attending HBOT (PA, NP)

HBOT is a medical procedure, the supervision of which requires an unrestricted medical license. Providing that an APP has satisfactorily completed their period of proctorship and is allowed under the terms of their health care facility’s medical staff bylaws, policies, procedures, state laws, and collaborative agreement, an APP may be granted privileges to attend HBOT for patients whose medical/surgical conditions are within their scope of license, education and experience, with the added proviso that an Independent Supervisor of HBOT is immediately available by telephone with a reasonable in-person response time according to hospital policy (generally considered to be within 30-40 minutes) while patients are undergoing HBOT.[6] 

The attending APP must be immediately available (as defined in Note i) to the chamber at all times throughout the HBOT session.[6] 

Immediately Available

• Note i: Attending providers are those directly overseeing a hyperbaric session. This individual is responsible for each patient and staff member who enters the chamber and undergoes treatment or exposure to hyperbaric conditions. Attending providers must remain immediately available (in person) to patients throughout the entirety of an HBOT or session.[6] 
• Attending an HBOT by telephone is unacceptable, as it neither constitutes immediate availability of the attending provider nor appropriate attendance of an HBOT.[6] 

Independent Supervisor of HBOT (MD/DO only)

• The UHMS defines Independent Supervisors of HBOT as individuals hold an unrestricted MD/DO license and, based on the criteria detailed in Part IV of the UHMS Guidelines for Credentialing, Privileging and Supervision of Hyperbaric Oxygen Therapy in the U.S.A., may independently attend HBOT without an additional qualified MD/DO providing direct supervision (attending) or being immediately available to respond throughout a patient’s HBOT. In addition, Independent Supervisors of HBOT, who have been privileged by the health care facility medical staff to do so, may supervise other MD/DO, PA, APRN (NP), DPM, and trainee providers who do not qualify to independently attend HBOT.[6] 

Minimum licensing, Education, and Training Standards for Attending Hyperbaric Oxygen Treatments

The scope of practice for an MD/DO or APP attending HBOT must include all components of patient evaluation necessary to evaluate the potential HBOT recipient and to ensure that there is no relative or absolute contraindication to treatment. The MD/DO or APP attending HBOT should be both cognizant of the potential hazards of the therapy and have the capability to immediately assess and appropriately manage complications should they arise. Documented training shall include the education, experience and expertise necessary to diagnose and treat UHMS-accepted indications as well as complications of HBOT. Potential complications include tension pneumothorax, respiratory decompensation secondary to aspiration, seizures, acute tympanic membrane injury, recognition and response to signs of oxygen toxicity and hypoxia as well as differentiation of these problems from anxiety or claustrophobia. All potential treatment of medical and surgical emergencies arising in the patient receiving HBOT must be within the scope of practice of the attending MD/DO or APP providing direct patient care, and the attending MD/DO or APP shall remain immediately available throughout the entire HBOT session (see Notes ii and iii).[6]

Hyperbaric Session

• Note iii: A hyperbaric session is defined as a single episode of: patient entry/placement into a chamber (regardless of the number of patients in the chamber at a given time), pressurization of the chamber, and completion of treatment under pressure, followed by depressurization and removal of the patient from the chamber. Each hyperbaric session shall include pre-treatment and post-treatment patient assessments. In monoplace chambers (where one patient is placed in the chamber), each hyperbaric session corresponds to a single treatment.[6]
  

Advanced Practice Providers (PA and NP) Must [6]

• Hold a valid license to practice medicine (in most states, PAs and many NPs will require an MD/DO ‘supervising physician’ under whose license they practice).
• The MD/DO identified to the State Medical Board as the supervising physician for an APP shall be privileged as an Independent Supervisor of HBOT within that facility or health care system.
• Document successful completion of a UHMS-approved Introductory Course in Hyperbaric Medicine (minimum standard).
• Undergo and document completion of a proctored experience program in HBOT.
• Demonstrate immediate in-person access to a Medical Director or Independent Supervisor of HBOT during HBOT
• Document successful completion of the UHMS PATH program within two (2) years of being granted privileges in hyperbaric medicine to maintain/satisfy credentialing criteria to attend HBOT

2020 UPDATES ON SUPERVISION

On November 1, 2019, CMS published a final rule effectuating changes to multiple sections of the Code of Federal Regulations (CFR), which took effect on January 1, 2020. The final rule, known as CY 2020 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1717-FC), includes a permanent alteration to the supervision requirements of 42 CFR §410.27.1 The specific change is to §410.27(a)(1)(iv), which previously required that covered services be performed under the direct supervision of a physician or non-physician practitioner (NPP) and now requires only general supervision by a physician or NPP.[7]

General supervision means that the procedure is furnished under the physician's overall direction and control, but that the physician's presence is not required during the performance of the procedure. This proposal would ensure a standard minimum level of supervision for each hospital service furnished incident to a physician’s service in accordance with the statute.[8]

The OPPS final rule only deals with hospital billing and payment. Whenever G0277 is billed to Medicare Part A on a hospital claim, there must be an associating professional code 99183 billed to Medicare Part B. The CPT® definition of 99183 is "Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session" which would mean the physician or other qualified health care professional must personally provide some aspect of care to the patient. The expectation of physician oversight has not changed for hyperbaric services. Therefore, we recommend that hyperbaric departments continue to provide direct supervision.[9]  See topic "Supervision of HBOT by Providers - Overview".