DOCUMENTATION TO SUPPORT MEDICAL NECESSITY IN HBOT

The following areas should be considered to minimize errors and be audit-ready:

• Documentation to support the dates of service billed may include, but is not limited to:

• • Treatment records (Dive sheets)
  • Signed DAILY order for HBO services
• Documentation to support medically necessity may include, but is not limited to:
• • Documentation to support services for treating a condition as described in CMS Pub 100-03, Medicare National Coverage Determination (NCD) Manual, Chapter 1, Coverage Determination, Section 20.29, Hyperbaric Oxygen therapy. [1]
  • History and Physical that clearly describes the condition for which HBOT is recommended
  • Physician progress note(s) that support all adjunctive therapies provided to the beneficiary in the treatment of the diagnosed condition
  • Laboratory and pathology report(s) if applicable
  • Radiology reports if applicable
  • Vascular studies if applicable
  • Documentation to support (at minimum) 30 days of failed conservative treatment(s) of wound with wound measurements if applicable
  • Operative and/or procedure reports related to the diagnosis if applicable
  • Date and anatomical site of radiation treatment if applicable
  • Prior antibiotic administration record to support chronic condition if applicable (i.e. chronic osteomyelitis)
  • HBOT procedure log(s) to include ascent time, decent time and pressurization level
  • Direct physician supervision
  • Assessment of condition (minimum) every 30 days during the HBOT
  • For condition where HBOT is covered when there is a threatened loss of function, limb, or life, the documentation must support the condition.
  • Advance Beneficiary Notice (ABN) if applicable 
  • Signature log or attestation statement for any missing or illegible signature within the medical record

• Sections with detailed documentation requirements, templates, and checklists for each specific HBOT indication can be found within each topic of the HBO Knowledge Base. See list of HBOT indications in " HBO Treatment Indications With Protocols".