Rule 23-202-5.1 - Hyperbaric Oxygen TherapyA. The Division of Medicaid defines Hyperbaric Oxygen Therapy (HBOT) as a modality in which the beneficiary's entire body is placed into the hyperbaric chamber and exposed to oxygen under increased atmospheric pressure. 1. The beneficiary is entirely enclosed in a pressure chamber breathing 100% oxygen (O 2) at greater than one atmosphere pressure. 2. Either a mono-place chamber pressurized with pure O 2 or a larger multi-place chamber pressurized with compressed air where the beneficiary receives pure O 2 by mask, head tent, or endotracheal tube may be used. B. The Division of Medicaid covers systemic HBOT in an inpatient or outpatient hospital setting in accordance with current standards of the Undersea and Hyperbaric Medical Society (UHMS) and when administered in a Food and Drug Administration (FDA) approved chamber. C. The Division of Medicaid covers HBOT for medical conditions that are FDA approved or that follow medically accepted indications supported by one (1) or more of the official compendia as designated by the Centers for Medicare and Medicaid (CMS) or the UHMS when the following criteria are met: 1. A physician or non-physician practitioner (NPP), practicing within their scope of practice, must: a) Order HBOT treatments which must include the estimated number of treatments and duration, b) Document medical necessity, c) Establish the plan of care which must: 1) Specify the goals for HBOT and 2) Include revisions as appropriate with justification for extending treatments. 2. A cardiopulmonary resuscitation (CPR) team and a fully equipped emergency cart must be immediately available where the hyperbaric chamber is located when a beneficiary is receiving HBOT in the event of a complication. 3. Emergency response procedures are in place that ensures timely beneficiary access to a hospital or acute care facility capable of providing emergent clinical support and treatment of any complications arising from hyperbaric therapy or, when indicated, the beneficiary's underlying disease processes for outpatient hospital HBOT facilities located on or off the hospital's campus. D. The Division of Medicaid requires HBOT treatment facilities to meet the UHMS standards for the number of trained and credentialed hyperbaric medicine physicians and non-physician providers on staff for appropriate treatment and medical care required by a beneficiary. 1. The Division of Medicaid defines: a) Direct supervision as supervision by a physician or non-physician provider (NPP) providing services within their scope of practice and hospital-granted privileges, the knowledge, skills, and ability in accordance with UHMS standards during a performed procedure in which the physician or NPP must be immediately available to furnish assistance and direction throughout the performance of the procedure. b) Immediately available as being in close physical proximity within the same building or connected building or structure, to where HBO2 treatments are provided and able to personally and physically attend to the chamber-side as soon as requested. 2. The Division of Medicaid requires a physician or NPP to provide direct supervision and be immediately available to the hyperbaric oxygen chamber(s) location while the beneficiary is receiving HBOT 3. NPPs may supervise HBOT services, if such service including definitive evaluation of the beneficiary is included within their 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 NPP meets required educational requirements. E. The Division of Medicaid does not cover topical application of oxygen with portable HBOT chambers. F. The Division of Medicaid reimburses the: 1. Hospital per beneficiary regardless if the HBOT is received in a mono or multi-place chamber per thirty (30) minute interval. 2. Physician or NPP per beneficiary session for attendance or supervision of HBOT. G. The Division of Medicaid requires the following documentation of medical necessity: 1. Must be maintained in the beneficiary's record and available for review upon request. 2. Must be legible and include appropriate beneficiary identification information and signature of the physician or non-physician practitioner responsible for and providing care to the patient. 3. Must support the use of the selected ICD-10-CM code(s) and CPT/HCPCS code must describe the service performed. 4. Documentation that a trained emergency response team is available and that the hospital setting provides the required availability of intensive care unit (ICU) services that could be needed to ensure the beneficiary's safety if a complication occurred. 5. Documentation present in the clinical record must provide an accurate description and diagnosis of the medical condition supporting that the use of HBOT is reasonable and medically necessary. The medical documentation must include but is not limited to the following: a) An initial assessment, which includes a history and physical that clearly substantiates the condition for which HBOT is recommended. This should also include any prior medical, surgical or HBOT treatments. b) Documentation of the procedure including ascent time, descent time and pressurization level. There should be a treatment plan identifying timeline and treatment goals. c) Physicians' progress notes that describe the physical findings, type(s) of treatment(s) provided, number of treatments provided, the effect of treatment(s) received and the assessment of the level of progress made toward achieving the completion of established therapy goals. d) Physician-to-physician communications or records of consultations, additional assessments, recommendations or procedural reports. e) Laboratory reports (cultures or Gram stains) that confirm the diagnosis of necrotizing fasciitis are required and must be present as support for payment of HBOT. f) X-ray findings and bone cultures confirming the diagnosis of osteomyelitis are required and must be present as support for payment of HBOT. g) Documentation to support the presence of gas gangrene as proven with laboratory reports (Gram stain or cultures) and X-ray. h) Documentation of date and anatomical site of prior radiation treatments. i) Documentation supporting date of skin graft and compromised state of graft site. j) For diabetic wounds of the lower extremity, the Wagner classification of the wound and the failure of an adequate course (at least 30 days) of standard wound therapy must be documented at the initiation of therapy. k) Specific written record of the physician's or NPP's direct supervision of the hyperbaric chamber while the beneficiary is undergoing HBOT; and l) Specific written record of the availability of a trained CPR team and a fully equipped emergency cart where the hyperbaric chamber is located while the beneficiary is undergoing HBOT.23 Miss. Code. R. § 202-5.1
42 U.S.C. § 1395y; 42 C.F.R. §§ 410.26, 410.27, 410.32; Miss. Code Ann. §§ 43-13-117, 43-13-121.Moved from Rule 1.5 and revised Rule 5.1.A. eff. 10/01/2013.