INTRODUCTION

To ensure audit-readiness and smooth reimbursement, facility and physician charges related to wound care and hyperbaric oxygen (HBO) services must be validated with documentation from both physician AND non-physician providers. The "burden of proof" remains with the physician AND non-physician providers, who should establish medical necessity for HBO services billed to the Centers for Medicare and Medicaid Services (CMS).

CMS has specific documentation requirements for HBO. Educating physicians and non-physician providers on these requirements is of utmost importance. 

Numerous studies regarding the frequency of error rates for hyperbaric services have been reported by CMS, OIG, Palmetto GBA, and Novitas, to name a few agencies. The reported error rates are disconcerting and have resulted in CMS Target Probe and Educate (TPE) audits and U.S. Office of Inspector General (OIG) retrospective documentation reviews. See topic "CMS Targeted Probe and Educate for HBOT Codes 99183 & G0277".

For instance, in 2013 the Medicare Administrative Contractor (MAC) Palmetto GBA reported a 58% error rate for HBO services.[1][2] Reasons given for denials included lack of documentation of “specific timelines and goals for therapy” and “monitoring for improvement or lack of improvement.” Denial reasons from the Palmetto HBO review of the 330 partially or completely denied claims include:

• No treatment plan in the documentation submitted. (84 occurrences)
• Treatment plan does not include goals for the therapy. (210 occurrences)
• Treatment plan does not include progress updates and patient’s response to therapy. (69 occurrences)
• Treatment plan does not include the number of sessions or length of the individual treatments. (13 occurrences)

The individual MACs have created documents to provide additional guidance for physician and non-physician providers.[3] As an example, First Coast JN and Novitas JH/JL have Local Coverage Determinations (LCD) for hyperbaric oxygen therapy that include the following statements as part of Documentation Requirements:

• “There should be a treatment plan identifying timeline and treatment goals.” And,
• “Physicians’ progress notes that describe … the effect of treatment(s) received and the assessment of the level of progress made toward achieving the completion of established therapy goals.”

To ensure that hyperbaric clinicians' documentation is audit-ready, we have created institutional and departmental policies that can be implemented at hyperbaric centers that bill CMS and commercial insurers.

DOCUMENTATION BY THE CHRN and CHT

Documentation by the Certified Hyperbaric Registered Nurses (CHRN) and the Certified Hyperbaric Technologists (CHT) is a crucial component as it details and confirms the services provided. Specifically, by validation of the physician or non-physician provider who has provided “direct supervision”. The CHRN and/or CHT note should “stand on its own” and provide a clear description of the treatment provided and actions taken in delivery of care at every patient visit.  

There are two considerations when discussing CHRN or CHT documentation: the impact on reimbursement and the medical-legal requirements:

• From a reimbursement perspective, CMS provides us with documentation that is required for reimbursement and denial and the associated denial codes/description following a TPE audit. The denial codes and description [4] are especially helpful in implementing documentation guidelines that will ensure compliance with the CMS requirements.  
• From a medical-legal perspective, documentation is essential because failure to document relevant data is itself considered a significant breach of, and deviation from, the standard of care. The patient record provides the only enduring version of the care as it evolves over time and a reference work of value.[5]

From a practical standpoint, there may be barriers that prevent meeting these requirements. For instance, the implementation of electronic medical records (EMR) has reduced the ability to provide narrative (i.e., free text) to the visit note. Typically, the wound care and hyperbaric EMR is a series of boxes to check with limited text fields for encapsulated data points (e.g., blood pressure, blood glucose level).  The unfortunate consequence is that the CHRN or CHT’s opportunity to “tell the story” of the visit, treatment or evaluation has been lost. 

Nevertheless, it is important to remind ourselves that the CHRN or CHT note is proof and validation that a treatment was provided and billed by the facility (G0277). In order to support the services provided, the hyperbaric treatment records should contain the information listed in this topic, compiled from relevant sources.[6][5][7][8] 

"Do not shortcut your documentation because of EMR limitations."  

Daily Treatment Documentation

At a minimum, the following should be included or documented by the CHRN or CHT, with every hyperbaric oxygen treatment:

• Patient name
• Date of treatment
• Verify physician diagnosis and treatment protocol
• Treatment number / total treatments ordered (e.g. 7 of 20)
• Chamber number (preferably serial number) identified as a “hard sided acrylic chamber”

Physician Order

There must be one signed order for every treatment that includes:

• Treatment indication
• Period of 100% oxygen breathing
• Treatment pressure
• Length of time at the prescribed pressure
• Rate of descent/ ascent
• Air breaks (if applicable)
• Cardiac monitoring (if applicable)
• Frequency of treatments (e.g. daily Monday through Friday)
• Blood glucose prior and following each treatment (physician order required with every treatment)

See physician orders templates in topic "HBO Physician Orders Overview"

Patient Assessment (by the CHRN or CHT)

• Mode of arrival (e.g. ambulatory, wheelchair)
• Appearance (e.g. alert, no apparent distress, color normal)
• Oriented to person, place, time
• Vital signs: Temperature, heart rate, blood pressure, respiratory rate (record actual values vs. generic statements such as “within normal values”)
• Breath sounds (e.g. clear, wheezes, rales, rhonchi)
• Blood glucose level (if applicable)
• Pain assessment 
• Medication taken prior to arrival?
• Previous treatment(s) tolerated or complaints

See details on patient assessment in topic "Patient Care"

Pre-treatment Safety Check (by the CHRN or CHT)

• Confirmation/Identification of patient (two identifiers)
• 100% cotton gown
• Prohibited item inspection
• Does the patient have any implanted devices?
• Foley, IV or drain secure (if applicable)
• Chamber ground confirmation
• Patient ground confirmation
• Air mask secure and operational
• Safety Time-out

See topics "Routine Inspection - Pre & Post-treatment checklists" and "Safety stops, checklists… when to document"

Documentation of the Treatment Log (by the CHRN or CHT)

• Time descent initiated
• Rate of descent
• Time patient reached the prescribed pressure
• Time air break(s) started and completed (if ordered)
• Time ascent initiated
• Rate of ascent 
• Time at ambient pressure
• Actual bottom time (Time reached prescribed pressure until time left prescribed pressure)
• Total treatment time (e.g. 106 minutes)

Physician Supervision (by the CHRN or CHT)

• The CHRN or CHT must document that the physician or non-physician provider was in attendance and provided direct supervision during the entire treatment.
• "Direct supervision" implies that the physician responsible for the procedure must be readily available to provide immediate physical presence for assistance and directions throughout the procedure (the physician does not have to be in the room for the procedure).[6]

Care Provided (by the CHRN or CHT)

• How was the treatment tolerated?
• Dressing change
• Negative pressure wound therapy disconnect/clamped for treatment
• Delivery of medication(s) or IV fluids

See topics "Patient Care" and "Nursing Interventions"

Plan of Care (by the CHRN or CHT, based on physician orders)

• Next scheduled treatment
• Next weekly evaluation by the consulting (ordering) hyperbaric physician. 
• Next evaluation to determine signs of progress towards goals of therapy
• Follow-up with the primary or referring physician
• Pending lab results
• Pending vascular or radiology studies

Weekly Clinician Evaluation

In addition to a thorough daily treatment note, consideration should be given to the utilization of a weekly nurse evaluation.  The weekly nurse evaluation should be scheduled prior to or after a daily treatment at a predetermined interval (day of the week) and should be performed in the wound center or somewhere other than on the stretcher next to the hyperbaric chamber.  The evaluation allows the patient and provider an opportunity to discuss progress toward the goals of therapy, the current plan of care and any concerns or complications that have occurred. 

Documentation should include the following :

• Patient name
  
• Date 

Hyperbaric Treatment

• Protocol
• Ordering physician 
• Total treatments ordered
• HBOT completed 
• ATA
• Air breaks: 
• Protocol modification(s) 
• Early ascent occurrence(s) 
• Prohibited items authorization(s)
• Adverse event occurrence(s) 

See topics "Go-No-Go Lists / Prohibited Items",  "Nursing Interventions"

Psychological Needs Assessment

• Dressing changes performed by: Home Health/ Family / Self
• Anxiety complicating compliance
• Pain adequately managed:
• Pain rating: 

See topics "Patient Care"

Comfort Measures During Therapy

• Communication:
• Temperature:
• Air Breaks:

Nutritional Needs Assessment

• Pre-albumin: Date MM/DD/YY, Value:  g/dl
• Albumin: Date MM/DD/YY,  Value: g/dl
• Current Diet:
• Weight: 
• Height: 
• *BMI:
• *BMI Weight Status:                           

*BMI Calculations for Adult Only, according to CDC standards

See topics "Nutritional Screening for Wound Care and Hyperbaric Oxygen Therapy"

Factors Complicating Wound Healing

• None
• Vascular
• Infectious
• Mechanical
• Nutritional
• Tissue Edema

See topic "Wound Care"

Studies Reviewed / Date

• TCOM:
•  X-Ray: 
• MRI:
• Culture & Sensitivities:
• Vascular: 
• Doppler:
• Arteriogram:

See topic "Transcutaneous Oximetry"

Interventions or Actions to be Taken

• Facilitated consults that were ordered by physician (vascular, etc)
• Assisted with referral to home health agency  
• Helped coordinate imaging exams/labs or other testing

CONCLUSIONS

The landscape of wound care and hyperbaric facilities today is such that it is not a matter of IF your hyperbaric facility will be audited, but when. Our recommendation is that teams meet with the IT department and begin a systematic plan for incorporating this information into the EMR, adding hard stops which make data fields mandatory and allow for “free text”. Self-auditing all hyperbaric charts using the documentation guidelines CMS provides will ensure that your hyperbaric documentation is audit ready.