016-06-06 Ark. Code R. § 12

Current through Register Vol. 49, No. 6, June, 2024

Rule 016.06.06-012 - Ambulatory Surgical Center Update No. 64; Hospital Update No. 91 and Physician/Independent Lab/CRNA/Radiation Therapy Center Update No. 109

Section II Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD)

217.130 Hyperbaric Oxygen Therapy 6-1-06

Hyperbaric Oxygen Therapy (HBO) involves exposing the body to oxygen under pressure greater than one atmosphere. Such therapy is performed in specially constructed hyperbaric chambers holding one or more patients, although, oxygen may be administered in addition to the hyperbaric treatment itself. Patients should be assessed for contraindications such as sinus disease or claustrophobia prior to therapy. In some diagnoses, hyperbarics is only an adjunct to standard surgical therapy. These indications are taken from "The Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and Hyperbaric Medical Society (Kensington, MD).

All hyperbaric therapy will require prior approval, except in emergency cases such as for air embolism or carbon monoxide poisoning. Prior approval will be for a certain number of treatments. A copy of the approval letter must be filed with each claim and the number in the series of treatments documented. Further treatments will require reapplication for a prior approval. Documentation for prior approval should include, but not be limited to, a complete physician SOAP note, a physical exam and prior therapy treatment failures, including antibiotic therapies and surgical interventions. It must include a clear description of the wound with each claim. Documentation of no measurable signs of healing for at least 30 consecutive days of wound care therapy prior to the start of HBO therapy should be included (for those diagnoses requiring this treatment plan). If an extension of benefits is needed, the above documentation must be submitted. Physician progress notes with physical findings at each treatment and the effects of treatment and wound description will be needed for an extension. Any questions may be addressed to the Medical Director at 501-682-9868.

Requests for prior approval may be mailed or faxed.

Mailing address:	Fax to:
ATTN: Medical Director	501-682-8013 or
Division of Medical Services	501-683-4124
P. O. Box 1437, Slot S412	ATTN: Medical Director
Little Rock, AR 72203-1437

The following tables provide explanation of diagnosis requirements and treatment number and treatment schedules.

Diagnosis	Description	Number of Treatments
6396, 67300, 9580, 9991	Air or Gas Embolism	10
9930	Decompression Sickness	10
986	Carbon Monoxide Poisoning	5
0400, 0383	Clostridial Myositis and Myonecrosis (Gas Gangrene)	10
8690-8691, 8871, 8873, 8875, 8877, 8971, 8973, 8975, 8977, 9251-9299, 99690-99699	Crush injuries, compartment syndrome, other acute traumatic peripheral ischemias	See Table
25070-25073, 44023, 44024, 44381-4439, 4540, 4542, 70700-7079, 9895, 99859	Enhancement of healing in selected problem wounds; diabetic foot ulcers, pressure ulcers, venous stasis ulcers; only in severe and limb or life-threatening wounds that have not responded to other treatments, particularly if ischemia that cannot be corrected by vascular procedures is present	30
3240	Intracranial abscess, multiple abscesses, immune compromise, unresponsive	20
72886, 7854	Necrotizing Soft Tissue Infections, immune compromise	30
73000-73020	Refractory osteomyelitis after aggressive surgical debredement	40
52689, 73010-73019, 7854, 9092, 990	Delayed Radiation Injury	60
99652, 99660-99670, V423	Compromised skin grafts and flaps	20
9400-9495	Thermal burns[GREATER THAN]20% TSBA +/or involvement of hands, face, feet or perineum that are deep, partial or full thickness injury	40
Hyperbaric Treatment Schedules ("Doses") of HBO₂
ICD9 Code	Injury Type	Number & Schedule of HBO₂ Treatments	Number of HBO₂Treatments Before Peer Review (Days)	Comments
9251-929.9	Crush Injuries according to Gustilo classification	TIDª 2 days BID''2 days Daily for 2 days	6
9585	Compartment syndrome, impending stage fasciotomy not required	TIDª for 1 day	1	If post-fasciotomy, see problem wound recommendations
9400-9495, 99652, 99666-99670, V423	Threatened flaps & grafts	Same as for crush injuries	6
92951-929.9	Problem wounds after primary management	BID for 7d; daily 7 days	14	Post-fasciotomy wounds, complications and residual wounds after primary management of crush injuries
73000-73020	Refractory osteomyelitis	Daily for 21 days	21 +	May require continuation of HBO₂ through 60 treatments, but reassessment and second stage peer review recommended after 40 treatments

ªThree times a day -Twice a day

Refer to section 272.404 of this manual for billing instructions.

272.404 Hyperbaric Oxygen Therapy Procedures 6-1-06

A.Facilities may bill for only one unit of service per day. The facility's charge for each service date must include all its hyperbaric oxygen therapy charges, regardless of how many treatment sessions per day are administered.

B. Facilities may bill for laboratory, X-ray, machine tests and outpatient surgery in addition to procedure code 99183.

C. Hospitals and ambulatory surgical centers must file paper claims for procedure code 99183 because the claims are reviewed for medical necessity.

D. Indicate which treatment session is being billed (for example, "Treatment session # 4") and attach pertinent progress and treatment notes.

Procedure Code	Description
99183	Hyperbaric oxygen pressurization, facility charge, one per day, outpatient

Refer to section 217.130 of this manual for coverage policy, diagnosis requirements and treatment schedules.

Physician/Independent Lab/CRNA/Radiation Therapy Center

258.000 Hyperbaric Oxygen Therapy

Physicians may be reimbursed for attendance and supervision of hyperbaric oxygen therapy.

Hyperbaric oxygen therapy involves exposing the body to oxygen under pressure greater than one atmosphere. Such therapy is performed in specially constructed hyperbaric chambers holding one or more patients; although oxygen may be administered in addition to the hyperbaric treatment. Patients should be assessed for contraindications such as sinus disease or claustrophobia prior to therapy. In some diagnoses, hyperbarics is only an adjunct to standard surgical therapy. These indications are taken from "The Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and Hyperbaric Medical Society (Kensington, MD).

A. All hyperbaric therapy will require prior approval, except in emergency cases such as for air embolism or carbon monoxide poisoning. Prior approval will be for a certain number of treatments. A copy of the approval letter must be filed with each claim and the number in the series of treatments documented.

B. Further treatments will require reapplication for a prior approval. Documentation for prior approval should include, but not be limited to, a complete physician SOAP note, a physical exam and prior therapy treatment failures, including antibiotic therapies and surgical interventions.

1. It must include a clear description of the wound with each claim. Documentation of no measurable signs of healing for at least 30 consecutive days of wound care therapy prior to the start of HBO therapy should be included (for those diagnoses requiring this treatment plan).

2. If an extension of benefits is needed, the above documentation must be submitted and fully documented. Physician progress notes physical findings at each treatment and the effects of treatment wound description will be needed for an extension. Any questions may be addressed to the Medical Director at 501-682-9868.

3. Requests for prior approval may be mailed or faxed.

Mailing address:	Fax to
ATTN: Medical Director	501-682-8013 or
Division of Medical Services	501-683-4124
Slot S412	ATTN: Medical Director
Department of Health and Human Services
PO Box 1437
Little Rock, AR 72203-1437

C. The following tables provide explanation of diagnosis requirements and treatment number of treatments and treatment schedules.

Diagnosis	Description	Number of Treatments
6396, 67300, 9580,9991	Air or Gas Embolism	10
9930	Decompression Sickness	10
986	Carbon Monoxide Poisoning	5
0400, 0383	Clostridial Myositis and Myonecrosis (Gas Gangrene)	10
8690-8691, 8871, 8873, 8875, 8877, 8971, 8973, 8975, 8977, 9251-9299, 99690-99699	Crush injuries, compartment syndrome, other acute traumatic peripheral ischemias	See Table
25070-25073, 44023, 44024, 44381-4439, 4540, 4542, 70700-7079, 9895, 99859	Enhancement of healing in selected problem wounds; diabetic foot ulcers, pressure ulcers, venous stasis ulcers; only in severe and limb or life-threatening wounds that have not responded to other treatments, particularly if ischemia that cannot be corrected by vascular procedures is present	30
3240	Intracranial abscess, multiple abscesses, immune compromise, unresponsive	20
72886, 7854	Necrotizing Soft Tissue Infections, immune compromise	30
73000-73020	Refractory osteomyelitis after aggressive surgical debredement	40
52689, 73010-73019, 7854, 9092, 990	Delayed Radiation Injury	60
99652, 99660-99670, V423	Compromised skin grafts and flaps	20
9400-9495	Thermal burns [GREATER THAN] 20% TSBA +/or involvement of hands, face, feet or perineum that are deep, partial or full thickness injury	40
Hyperbaric Treatment Schedules ("Doses") of HBO₂
ICD9 Code	Injury Type	Number & Schedule of HBO₂ Treatments	Number of HBO₂Treatments Before Peer Review (Days)	Comments
9251-929.9	Crush Injuries according to Gustilo classification	TID^a 2 days BID^b 2 days Daily for 2 days	6
9585	Compartment syndrome, impending stage fasciotomy not required	TID^a for 1 day	1	If post-fasciotomy, see problem wound recommendations
9400-9495, 99652, 99666-99670, V423	Threatened flaps & grafts	Same as for crush injuries	6
92951-929.9	Problem wounds after primary management	BID^b for 7d; daily 7 days	14	Post-fasciotomy wounds, complications and residual wounds after primary management of crush injuries
73000-73020	Refractory osteomyelitis	Daily for 21 days	21 +	May require continuation of HBO₂ through 60 treatments, but reassessment and second stage peer review recommended after 40 treatments

^aThree times a day ^bTwice a day

Refer to section 292.860 of this manual for billing instructions.

292.860 Hyperbaric Oxygen Therapy Procedures 6-1-06

Physicians may be reimbursed for attendance and supervision of hyperbaric oxygen therapy. Physicians billing for the physician component of "Physician attendance and supervision of hyperbaric oxygen therapy" may bill for only one unit of service per day. The physician's charge for each service date must include all his or her hyperbaric oxygen therapy charges, regardless of how many treatment sessions per day are administered.

A. Physicians may bill for surgery and professional components of anatomical lab procedures, X-rays and machine tests in addition to 99183.

B. Physicians must file paper claims for 99183 because the claims are reviewed for medical necessity.

1. Indicate which treatment session is being billed (for example, "Treatment session # 4") and attach pertinent progress and treatment notes.

2. Use type of service code "1" (paper claims only).

Refer to section 258.000 of this manual for coverage policy, diagnosis requirements and treatment schedules.

Ambulatory Surgical Center

216.800 Hyperbaric Oxygen Therapy 6-1-06

Hyperbaric Oxygen Therapy (HBO) involves exposing the body to oxygen under pressure greater than one atmosphere. Such therapy is performed in specially constructed hyperbaric chambers holding one or more patients, although oxygen may be administered in addition to the hyperbaric treatment itself. Patients should be assessed for contraindications such as sinus disease or claustrophobia prior to therapy. In some diagnoses, hyperbarics is only an adjunct to standard surgical therapy. These indications are taken from "The Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and Hyperbaric Medical Society (Kensington, MD).

Requests for prior approval may be mailed or faxed.

Mailing address:	Fax to:
ATTN: Medical Director	501-682-8013 or
Division of Medical Services	501-683-4124
P. O. Box 1437, Slot S412	ATTN: Medical Director
Little Rock, AR 72203-1437

The following tables provide explanation of diagnosis requirements and treatment number and treatment schedules.

		Number of
Diagnosis	Description	Treatments
6396, 67300, 9580, 9991	Air or Gas Embolism	10
9930	Decompression Sickness	10
986	Carbon Monoxide Poisoning	5
0400, 0383	Clostridial Myositis and Myonecrosis (Gas Gangrene)	10
8690-8691, 8871, 8873, 8875, 8877, 8971, 8973, 8975, 8977, 9251-9299, 99690-99699	Crush injuries, compartment syndrome, other acute traumatic peripheral ischemias	See Table
25070-25073, 44023, 44024, 44381-4439, 4540, 4542, 70700-7079, 9895, 99859	Enhancement of healing in selected problem wounds; diabetic foot ulcers, pressure ulcers, venous stasis ulcers; only in severe and limb or life-threatening wounds that have not responded to other treatments, particularly if ischemia that cannot be corrected by vascular procedures is present	30
3240	Intracranial abscess, multiple abscesses, immune compromise, unresponsive	20
72886, 7854	Necrotizing Soft Tissue Infections, immune compromise	30
73000-73020	Refractory osteomyelitis after aggressive surgical debredement	40
52689, 73010-73019, 7854, 9092, 990	Delayed Radiation Injury	60
99652, 99660-99670, V423	Compromised skin grafts and flaps	20
9400-9495	Thermal burns[GREATER THAN]20% TSBA +/or involvement of hands, face, feet or perineum that are deep, partial or full thickness injury	40
Hyperbaric Treatment Schedules ("Doses") of HBO₂
		Number & Schedule of HBO₂	Number of HBO₂Treatments Before Peer
ICD9 Code	Injury Type	Treatments	Review (Days)	Comments
9251-929.9	Crush Injuries according to Gustilo classification	TIDª 2 days BID''2 days Daily for 2 days	6
9585	Compartment syndrome, impending stage fasciotomy not required	TIDª for 1 day	1	If post-fasciotomy, see problem wound recommendations
9400-9495, 99652, 99666-99670, V423	Threatened flaps & grafts	Same as for crush injuries	6
92951-929.9	Problem wounds after primary management	BID- for 7d; daily 7 days	14	Post-fasciotomy wounds, complications and residual wounds after primary management of crush injuries

Ambulatory Surgical Center

Hyperbaric Treatment Schedules ("Doses") of HBO₂

ICD9 Code

Injury Type

Number & Schedule of

HBO₂

Treatments

Number of HBO₂Treatments Before Peer Review (Days)

Comments

73000-73020

Refractory osteomyelitis

Daily for 21 days

21 +

May require continuation of HBO₂ through 60 treatments, but reassessment and second stage peer review recommended after 40 treatments

ªThree times a day ""Twice a day

Refer to section 242.145 of this manual for billing instructions.

242.145 Hyperbaric Oxygen Therapy Procedures 6-1-06

B. Facilities may bill for laboratory, X-ray, machine tests and outpatient surgery in addition to procedure code 99183.

C. Hospitals and ambulatory surgical centers must file paper claims for procedure code 99183 because the claims are reviewed for medical necessity.

D. Indicate which treatment session is being billed (for example, "Treatment session # 4") and attach pertinent progress and treatment notes.

Procedure Code	Description
99183	Hyperbaric oxygen pressurization, facility charge, one per day, outpatient

Refer to section 216.800 of this manual for coverage policy, diagnosis requirements and treatment schedules.

016.06.06 Ark. Code R. § 012

5/5/2006