Payment Strategies
Hyperbaric Oxygen Therapy Prior Authorization: Not an April Fool’s Joke! Kathleen D. Schaum, MS
For years, this author has been teaching wound care professionals that they should always verify the patient’s insurance benefits before providing care. If the patient’s insurance is Medicare Advantage, a private payer, Tricare, Worker’s Compensation, Medicaid, and so on, and if the payer says the product/procedure/service is covered on the patient’s plan, then the professional should inquire if prior authorization is required. If the answer is yes, the wound care professional should ask the payer for (1) a list of the required documentation, (2) a prior authorization form (if the payer has one), (3) address to send the prior authorization request, and (4) how/when the payer will respond with their prior authorization decision. If the patient’s insurance is traditional fee-for-service Medicare, wound care professionals can verify that the patient paid his/her Medicare Part B premium, but they traditionally have not been able to obtain prior authorization from the Medicare Administrative Contractors (MACs) who process their claims. Instead, wound care professionals must follow any National Coverage Determinations (NCDs) and/or any Local Coverage Determinations (LCDs)/Articles that pertain to the product/procedure/ service they wish to provide for their patients (http://www. cms.gov/medicare-coverage-database/indexes/national-andlocal-indexes.aspx). If neither an NCD nor LCD exists, then the product/procedure/service may be covered based on medical necessity. See Table 1 for the current NCD, LCDs, and Articles pertinent to hyperbaric oxygen (HBO) therapy. Also for many years, this author has taught that coding, payment, and coverage rules can change at any time. This is one of those times, and this is not an April Fool’s joke! The Centers for Medicare & Medicaid Services (CMS) has begun a nonemergent HBO therapy prior authorization project for providers that submit HBO claims with bill type 13Vhospital-based outpatient wound care departments (HOPDs) in Illinois (serviced by MAC J6 National Government Services Inc), in Michigan (serviced by MAC J8 Wisconsin Physicians Service Insurance Corporation [WPS]), and in New Jersey (serviced by MAC JL Novitas Solutions, Inc [Novitas]). Be sure to note: The CMS is not the first payer to require prior authorization for HBO therapy. Some private payers, Tricare, certain Medicaid
program, and so on, already use prior authorization to ensure proper payment before HBO therapy is rendered. This is not the first prior authorization model initiated by CMS. You may be saying to yourself, ‘‘Why should I continue reading this article if I do not work in Illinois, Michigan, or New Jersey?’’ The answer is simple and important: When CMS begins such a project, it is only a matter of time until HOPDs across the country may be required to obtain prior authorization from the MAC that processes their Medicare claims. Therefore, HOPDs should read the prior authorization rules and make a concerted effort to ensure that their wound care professionals’ HBO therapy documentation and utilization of HBO therapy meet the NCD requirements and any LCD and/or Article requirements published by their MAC. Following are some of the most frequently asked questions that this author has received about the new nonemergent HBO therapy prior authorization project. Q: What is prior authorization? A: Prior authorization is a process through which a request of provisional affirmation of coverage is submitted for review before a service is rendered to a beneficiary and before a claim is submitted for payment. Q: Why did CMS initiate the nonemergent HBO therapy prior authorization project? A: The CMS wants to test whether prior authorization helps reduce expenditures, while maintaining or improving quality of care. The CMS believes using a prior authorization process will help ensure services are provided in compliance with applicable Medicare coverage, coding, and payment rules before HBO services are rendered and before claims are paid. The prior authorization process will confirm that the applicable coding, coverage (NCD, LCD, and Article), and payment rules are met. Q: Why did CMS select Illinois, Michigan, and New Jersey for the HBO therapy prior authorization project? A: The CMS stated that these 3 states were selected for initial implementation of the project because of their high HBO therapy utilization and improper HBO therapy payment rates. In addition, beneficiaries in these states had the highest average number of HBO therapy sessions by total expenditures. Q: The NCD lists 15 covered conditions. How many will be eligible for prior authorization?
Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms Schaum can be reached for questions and consultations by calling 561-964-2470 or through her e-mail address: [email protected]. Submit your questions for Payment Strategies by mail to: Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467. ADVANCES IN SKIN & WOUND CARE & VOL. 28 NO. 4
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Table 1.
CMS AND MEDICARE ADMINISTRATIVE CONTRACTOR’S HBO THERAPY NCDs, LCDs, AND ARTICLES (CURRENT AS OF FEBRUARY 14, 2015) CMS or MAC
NCD or LCD No.
NCD or LCD Name
Article No.
Article Name
CMS Cahaba Government Benefit Administrators, LLC CGS Administrators, LLC First Coast Service Options, Inc
NCD 20.29 NA
NCD for HBO therapy NA
NA A48900
NA Local Coverage Article: NCD - HBO therapy
L31872
LCD: HBO therapy
NA
NA
L28887 L29192 L28909 L29347
LCD: LCD: LCD: LCD:
Effective Effective Effective Effective A52555
National Government Services, Inc
NA
NA
A52174
Noridian Healthcare Solutions, LLC
NA
NA
Noridian Healthcare Solutions, LLC
NA
NA
Novitas Solutions, Inc JH Novitas Solutions, Inc JL Palmetto GBA
L32739
LCD: HBO therapy
A52835 A52836 A47187 A51787 A51788 NA
Coding guidelines Coding guidelines Coding guidelines Coding guidelines Local Coverage Article: HBO therapy revision to the Part A LCD Local Coverage Article: HBO therapy revision to the Part B LCD Local Coverage Article: HBO therapy Medical Policy Article Local Coverage Article: HBO therapy Local Coverage Article: HBO therapy Local Coverage Article: HBO and E/M codes Local Coverage Article: HBO therapy Local Coverage Article: HBO therapy NA
L32018
LCD: HBO therapy
A51277
Local Coverage Article: HBO therapy
NA
NA
A53603
Local Coverage Article: NCD HBO therapy
First Coast Service Options, Inc
HBO HBO HBO HBO
therapy therapy therapy therapy
A52556
01/01/2015 01/01/2015 01/01/2015 01/01/2015
Abbreviations: CMS, Centers for Medicare & Medicaid Services; HBO, hyperbaric oxygen; LCD, Local Coverage Determination; MAC, Medicare Administrative Contractor; NA, not applicable; NCD, National Coverage Determination.
A: Six of the conditions listed in the NCD will be eligible for prior authorization: preparation and preservation of compromised skin grafts (not for primary management of wounds) chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management osteoradionecrosis as an adjunct to conventional treatment soft tissue radionecrosis as an adjunct to conventional treatment actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment diabetic wounds of the lower extremities in patients who meet the following 3 criteria: ) Patient has type 1 or type 2 diabetes and has a lowerextremity wound that is due to diabetes. ) Patient has a wound classified as Wagner grade III or higher. ) Patient has failed an adequate course of wound therapy as defined in the NCD. Q: Will you please review the Medicare coverage requirements for HBO therapy? A: The coverage requirements that pertain to all HBO therapy providers are clearly listed in the Medicare NCD: WWW.WOUNDCAREJOURNAL.COM
HBO therapy is covered as an adjunctive therapy only after
there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible; optimization of nutritional status; optimization of glucose control; debridement by any means to remove devitalized tissue; maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings; appropriate off-loading; and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Q: When did the nonemergent HBO therapy prior authorization project begin?
153
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A: The MACs began accepting prior authorization requests on March 1, 2015, for HBO treatments of the 6 included conditions occurring on or after April 13, 2015. Q: Which HBO therapy HCPCS (Healthcare Common Procedure Coding System) code is subject to HOPD prior authorization? A: HCPCS code G0277 is subject to prior authorization when HBO is provided by an HOPD. Q: If the HOPD uses C1300 instead of the new code G0277 on the Medicare claim form, can the HOPD bypass the HBO therapy prior authorization? A: No. CMS deleted C1300 as a code for any HBO therapy services that are performed effective January 1, 2015. The deleted code was replaced with G0277, hyperbaric oxygen under pressure, full body chamber, per 30 minute interval. If a claim is submitted to Medicare for an HBO service performed in an HOPD any time after December 31, 2014, the claim will be rejected. Q: Does the HBO therapy prior authorization project require any new documentation? A: No, the prior authorization project does not have any new clinical documentation requirements. The project requires the same information necessary to support Medicare payment. However, the documentation must be proactively submitted earlier in the claims process. Prior authorization should allow providers and suppliers to (1) address issues with HBO claims prior to rendering services and (2) avoid an appeals process. The process will help ensure that all relevant coverage, coding, and clinical documentation requirements are met before the service is rendered to the beneficiary and before the claim is submitted for payment. Q: What information is required by CMS in the HBO therapy prior authorization request? A: The prior authorization request must identify the following: the beneficiary’s name, Medicare number, date of birth, and gender the ordering physician’s name, National Provider Identifier (NPI), provider transaction access number (PTAN), and address the HOPD name, PTAN, NPI, and address the requestor’s name and telephone number procedure code submission date start of the 12-month period number of treatments requested diagnosis codes indicate if the request is an initial or resubmission review indicate if the request is expedited and the reason why The request must also include the following: documentation from the medical record to support the medical necessity for the HBO therapy any other relevant document that is deemed necessary by the MAC, for example: ADVANCES IN SKIN & WOUND CARE & VOL. 28 NO. 4
) documentation supporting date of skin graft and compromised state of graft site ) history and physical ) prior medical, surgical, and/or previous HBO therapy ) prior antibiotic therapy and surgical interventions or any adjunctive treatment currently being rendered ) procedure logsVincluding ascent time, descent time, and pressurization level ) laboratory reports (culture or gram stains) confirming the diagnosis of actinomycosis ) X-ray findings and/or bone cultures confirming the diagnosis of chronic refractory osteomyelitis and what forms of medical/surgical management were tried and failed ) legible, signed physician order for the service(s) billed HBO therapy providers should visit their MAC’s website to read specific prior authorization submission directions (eg, frequently asked questions, prior authorization mailing addresses, instructions for completing the prior authorization request cover sheets, prior authorization submission checklist for the prior authorization request) and specific documentation required by the MAC. Some MACs may provide a prior authorization submission cover sheet and a submission form. Table 2 lists the links to the websites of the MACs who are participating in the nonemergent HBO therapy prior authorization project. Q: How many HBO treatments will the MACs prior authorize? A: The MACs’ provisional affirmative prior authorization decision may affirm up to 40 HBO treatments in a 12-month period. A new prior authorization must be submitted if more than 40 HBO treatments are needed. Q: How should the HOPD submit the prior authorization request? A: The HOPD may submit the prior authorization request in 1 of 4 ways: via mail via fax via the Electronic Submission of Medical Documentation (esMD) system. HOPDs can learn about this at www.cms.gov/esMD. via the MAC’s provider portal, if one is available
Table 2.
LINKS TO WEBSITES OF MACS PARTICIPATING IN NONEMERGENT HBO THERAPY PRIOR AUTHORIZATION PROJECT MAC
Link to Website
National Government Services, Inc Novitas Solutions, Inc Wisconsin Physicians Service Insurance Corporation
http://www.ngsmedicare.com http://www.novitas-solutions.com http://www.wpsmedicare.com
Abbreviation: MAC, Medicare Administrative Contractor.
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Q: When should the HBO prior authorization be requested? A: The prior authorization should be requested as soon as the HBO treatment is scheduled. Q: Has CMS established a timeline for the MACs to respond to the HBO prior authorization requests? A: The MACs are supposed to make every effort to review the HBO prior authorization request and postmark decision letters within 10 business days. If the HOPD submits an expedited HBO prior authorization because the standard processing timeframe could jeopardize the life or health of the beneficiary, the MACs are supposed to make a reasonable effort to communicate a decision within 2 business days. If the initial prior authorization request was nonaffirmed, the HOPD can resolve the nonaffirmative reason described in the decision letter and resubmit the prior authorization request. The MACs are supposed to make every effort to review the resubmitted request and postmark decision letters within 20 business days. Note: Unlimited resubmissions are allowed for nonaffirmed prior authorizations, but these requests are not appealable. Q: Should HBO treatment be delayed until the prior authorization decision is made? A: The CMS has stated that HBO treatment should not be delayed because of a pending prior authorization and that an affirmed prior authorization decision will retroactively apply to the start date requested on the prior authorization request. Note: Claims should not be submitted to the MAC until the prior authorization decision has been received. Q: If the HBO prior authorization is not affirmed by the MAC, will the MAC explain why? A: Yes. The MAC will provide a detailed written explanation that will outline the specific policy requirement(s) that was/were not met. Q: Does the HOPD have any options if the HBO prior authorization request is not affirmed by the MAC? A: Yes, the HOPD has 2 choices: The HOPD can (a) resolve the specific HBO policy requirements that were not met and that were described in the MAC’s decision letter, and (b) resubmit the prior authorization request. The CMS allows unlimited prior authorization resubmissions. Note: Prior authorization request decisions are not appealable. The HOPD can provide the HBO therapy and submit a claim. The claim will automatically be denied. Note: All appeal rights will be available to the HOPD. Q: Once an affirmative decision is received from the MAC, how should the HOPD communicate that on their Medicare claim?
WWW.WOUNDCAREJOURNAL.COM
A: The MAC’s affirmative decision letter will include the prior authorization unique tracking number (UTN), which the HOPD should submit on their claim. If the HOPD submits electronic 837 institutional claims, the UTN should be submitted at the 2300VClaim Information level in the Prior Authorization reference (REF) segment where REF01 = ‘‘G1’’ qualifier and REFO2 = UTN. If the HOPD submits paper CMS 1450 Claim forms, the UTN should be submitted in Form Locator 63. The UTN should be submitted on the same line (A, B, C) that Medicare is shown in Form Locator 50 (Payer Line A, B, C). The UTN should begin in position 1 of Form Locator 63. Q: What will happen if an HOPD in Illinois, Michigan, or New Jersey does not request HBO prior authorization, provides HBO therapy to a Medicare patient, and submits a claim to the MAC? A: When the MAC receives the claim, the MAC will stop the claim for prepayment review, send an Additional Document Request (ADR) to the HOPD, and wait 45 days for a response. Once the MAC receives the requested documentation, they will review it within 60 days. Q: Will the beneficiary be notified about the MAC’s prior authorization determination? A: Upon request, the beneficiary will be notified whether Medicare will pay for the HBO. Q: Are critical access hospitals or facilities included in this model? A: No. Critical access hospitals do not use the G0277 code and are not included in this prior authorization model. Q: Do qualified healthcare professionals (QHPs) need to request prior authorization from their MAC before they attend and provide supervision to HBO therapy performed in HOPDs? A: No. QHPs do not need to request MAC prior authorization. This nonemergent HBO therapy prior authorization project is only for the facility Medicare payment portion of the HBO therapy service. However, it is in the best interest of QHPs to check if the HOPD has received MAC prior authorization or a nonaffirmed MAC prior authorization. Reason: If the HOPD does not have a prior authorization or has a nonaffirmed prior authorization, the associated QHP claim with 99183 physician attendance and supervision of hyperbaric oxygen, per session will be subject to medical review. Q: Does CMS have any educational resources regarding the HBO prior authorization project? A: Yes, you can find a plethora of information (eg, fact sheet, frequently asked questions, background information, recordings and slides from CMS Open Door Forums) on the CMS website: http://go.cms.gov/PAHBO. In addition you can send questions to [email protected].
155
&
ADVANCES IN SKIN & WOUND CARE & APRIL 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Hyperbaric Oxygen Therapy Prior Authorization: Not an April Fool’s Joke! Kathleen D. Schaum, MS
For years, this author has been teaching wound care professionals that they should always verify the patient’s insurance benefits before providing care. If the patient’s insurance is Medicare Advantage, a private payer, Tricare, Worker’s Compensation, Medicaid, and so on, and if the payer says the product/procedure/service is covered on the patient’s plan, then the professional should inquire if prior authorization is required. If the answer is yes, the wound care professional should ask the payer for (1) a list of the required documentation, (2) a prior authorization form (if the payer has one), (3) address to send the prior authorization request, and (4) how/when the payer will respond with their prior authorization decision. If the patient’s insurance is traditional fee-for-service Medicare, wound care professionals can verify that the patient paid his/her Medicare Part B premium, but they traditionally have not been able to obtain prior authorization from the Medicare Administrative Contractors (MACs) who process their claims. Instead, wound care professionals must follow any National Coverage Determinations (NCDs) and/or any Local Coverage Determinations (LCDs)/Articles that pertain to the product/procedure/ service they wish to provide for their patients (http://www. cms.gov/medicare-coverage-database/indexes/national-andlocal-indexes.aspx). If neither an NCD nor LCD exists, then the product/procedure/service may be covered based on medical necessity. See Table 1 for the current NCD, LCDs, and Articles pertinent to hyperbaric oxygen (HBO) therapy. Also for many years, this author has taught that coding, payment, and coverage rules can change at any time. This is one of those times, and this is not an April Fool’s joke! The Centers for Medicare & Medicaid Services (CMS) has begun a nonemergent HBO therapy prior authorization project for providers that submit HBO claims with bill type 13Vhospital-based outpatient wound care departments (HOPDs) in Illinois (serviced by MAC J6 National Government Services Inc), in Michigan (serviced by MAC J8 Wisconsin Physicians Service Insurance Corporation [WPS]), and in New Jersey (serviced by MAC JL Novitas Solutions, Inc [Novitas]). Be sure to note: The CMS is not the first payer to require prior authorization for HBO therapy. Some private payers, Tricare, certain Medicaid
program, and so on, already use prior authorization to ensure proper payment before HBO therapy is rendered. This is not the first prior authorization model initiated by CMS. You may be saying to yourself, ‘‘Why should I continue reading this article if I do not work in Illinois, Michigan, or New Jersey?’’ The answer is simple and important: When CMS begins such a project, it is only a matter of time until HOPDs across the country may be required to obtain prior authorization from the MAC that processes their Medicare claims. Therefore, HOPDs should read the prior authorization rules and make a concerted effort to ensure that their wound care professionals’ HBO therapy documentation and utilization of HBO therapy meet the NCD requirements and any LCD and/or Article requirements published by their MAC. Following are some of the most frequently asked questions that this author has received about the new nonemergent HBO therapy prior authorization project. Q: What is prior authorization? A: Prior authorization is a process through which a request of provisional affirmation of coverage is submitted for review before a service is rendered to a beneficiary and before a claim is submitted for payment. Q: Why did CMS initiate the nonemergent HBO therapy prior authorization project? A: The CMS wants to test whether prior authorization helps reduce expenditures, while maintaining or improving quality of care. The CMS believes using a prior authorization process will help ensure services are provided in compliance with applicable Medicare coverage, coding, and payment rules before HBO services are rendered and before claims are paid. The prior authorization process will confirm that the applicable coding, coverage (NCD, LCD, and Article), and payment rules are met. Q: Why did CMS select Illinois, Michigan, and New Jersey for the HBO therapy prior authorization project? A: The CMS stated that these 3 states were selected for initial implementation of the project because of their high HBO therapy utilization and improper HBO therapy payment rates. In addition, beneficiaries in these states had the highest average number of HBO therapy sessions by total expenditures. Q: The NCD lists 15 covered conditions. How many will be eligible for prior authorization?
Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms Schaum can be reached for questions and consultations by calling 561-964-2470 or through her e-mail address: [email protected]. Submit your questions for Payment Strategies by mail to: Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467. ADVANCES IN SKIN & WOUND CARE & VOL. 28 NO. 4
152
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Payment Strategies
Table 1.
CMS AND MEDICARE ADMINISTRATIVE CONTRACTOR’S HBO THERAPY NCDs, LCDs, AND ARTICLES (CURRENT AS OF FEBRUARY 14, 2015) CMS or MAC
NCD or LCD No.
NCD or LCD Name
Article No.
Article Name
CMS Cahaba Government Benefit Administrators, LLC CGS Administrators, LLC First Coast Service Options, Inc
NCD 20.29 NA
NCD for HBO therapy NA
NA A48900
NA Local Coverage Article: NCD - HBO therapy
L31872
LCD: HBO therapy
NA
NA
L28887 L29192 L28909 L29347
LCD: LCD: LCD: LCD:
Effective Effective Effective Effective A52555
National Government Services, Inc
NA
NA
A52174
Noridian Healthcare Solutions, LLC
NA
NA
Noridian Healthcare Solutions, LLC
NA
NA
Novitas Solutions, Inc JH Novitas Solutions, Inc JL Palmetto GBA
L32739
LCD: HBO therapy
A52835 A52836 A47187 A51787 A51788 NA
Coding guidelines Coding guidelines Coding guidelines Coding guidelines Local Coverage Article: HBO therapy revision to the Part A LCD Local Coverage Article: HBO therapy revision to the Part B LCD Local Coverage Article: HBO therapy Medical Policy Article Local Coverage Article: HBO therapy Local Coverage Article: HBO therapy Local Coverage Article: HBO and E/M codes Local Coverage Article: HBO therapy Local Coverage Article: HBO therapy NA
L32018
LCD: HBO therapy
A51277
Local Coverage Article: HBO therapy
NA
NA
A53603
Local Coverage Article: NCD HBO therapy
First Coast Service Options, Inc
HBO HBO HBO HBO
therapy therapy therapy therapy
A52556
01/01/2015 01/01/2015 01/01/2015 01/01/2015
Abbreviations: CMS, Centers for Medicare & Medicaid Services; HBO, hyperbaric oxygen; LCD, Local Coverage Determination; MAC, Medicare Administrative Contractor; NA, not applicable; NCD, National Coverage Determination.
A: Six of the conditions listed in the NCD will be eligible for prior authorization: preparation and preservation of compromised skin grafts (not for primary management of wounds) chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management osteoradionecrosis as an adjunct to conventional treatment soft tissue radionecrosis as an adjunct to conventional treatment actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment diabetic wounds of the lower extremities in patients who meet the following 3 criteria: ) Patient has type 1 or type 2 diabetes and has a lowerextremity wound that is due to diabetes. ) Patient has a wound classified as Wagner grade III or higher. ) Patient has failed an adequate course of wound therapy as defined in the NCD. Q: Will you please review the Medicare coverage requirements for HBO therapy? A: The coverage requirements that pertain to all HBO therapy providers are clearly listed in the Medicare NCD: WWW.WOUNDCAREJOURNAL.COM
HBO therapy is covered as an adjunctive therapy only after
there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible; optimization of nutritional status; optimization of glucose control; debridement by any means to remove devitalized tissue; maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings; appropriate off-loading; and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Q: When did the nonemergent HBO therapy prior authorization project begin?
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A: The MACs began accepting prior authorization requests on March 1, 2015, for HBO treatments of the 6 included conditions occurring on or after April 13, 2015. Q: Which HBO therapy HCPCS (Healthcare Common Procedure Coding System) code is subject to HOPD prior authorization? A: HCPCS code G0277 is subject to prior authorization when HBO is provided by an HOPD. Q: If the HOPD uses C1300 instead of the new code G0277 on the Medicare claim form, can the HOPD bypass the HBO therapy prior authorization? A: No. CMS deleted C1300 as a code for any HBO therapy services that are performed effective January 1, 2015. The deleted code was replaced with G0277, hyperbaric oxygen under pressure, full body chamber, per 30 minute interval. If a claim is submitted to Medicare for an HBO service performed in an HOPD any time after December 31, 2014, the claim will be rejected. Q: Does the HBO therapy prior authorization project require any new documentation? A: No, the prior authorization project does not have any new clinical documentation requirements. The project requires the same information necessary to support Medicare payment. However, the documentation must be proactively submitted earlier in the claims process. Prior authorization should allow providers and suppliers to (1) address issues with HBO claims prior to rendering services and (2) avoid an appeals process. The process will help ensure that all relevant coverage, coding, and clinical documentation requirements are met before the service is rendered to the beneficiary and before the claim is submitted for payment. Q: What information is required by CMS in the HBO therapy prior authorization request? A: The prior authorization request must identify the following: the beneficiary’s name, Medicare number, date of birth, and gender the ordering physician’s name, National Provider Identifier (NPI), provider transaction access number (PTAN), and address the HOPD name, PTAN, NPI, and address the requestor’s name and telephone number procedure code submission date start of the 12-month period number of treatments requested diagnosis codes indicate if the request is an initial or resubmission review indicate if the request is expedited and the reason why The request must also include the following: documentation from the medical record to support the medical necessity for the HBO therapy any other relevant document that is deemed necessary by the MAC, for example: ADVANCES IN SKIN & WOUND CARE & VOL. 28 NO. 4
) documentation supporting date of skin graft and compromised state of graft site ) history and physical ) prior medical, surgical, and/or previous HBO therapy ) prior antibiotic therapy and surgical interventions or any adjunctive treatment currently being rendered ) procedure logsVincluding ascent time, descent time, and pressurization level ) laboratory reports (culture or gram stains) confirming the diagnosis of actinomycosis ) X-ray findings and/or bone cultures confirming the diagnosis of chronic refractory osteomyelitis and what forms of medical/surgical management were tried and failed ) legible, signed physician order for the service(s) billed HBO therapy providers should visit their MAC’s website to read specific prior authorization submission directions (eg, frequently asked questions, prior authorization mailing addresses, instructions for completing the prior authorization request cover sheets, prior authorization submission checklist for the prior authorization request) and specific documentation required by the MAC. Some MACs may provide a prior authorization submission cover sheet and a submission form. Table 2 lists the links to the websites of the MACs who are participating in the nonemergent HBO therapy prior authorization project. Q: How many HBO treatments will the MACs prior authorize? A: The MACs’ provisional affirmative prior authorization decision may affirm up to 40 HBO treatments in a 12-month period. A new prior authorization must be submitted if more than 40 HBO treatments are needed. Q: How should the HOPD submit the prior authorization request? A: The HOPD may submit the prior authorization request in 1 of 4 ways: via mail via fax via the Electronic Submission of Medical Documentation (esMD) system. HOPDs can learn about this at www.cms.gov/esMD. via the MAC’s provider portal, if one is available
Table 2.
LINKS TO WEBSITES OF MACS PARTICIPATING IN NONEMERGENT HBO THERAPY PRIOR AUTHORIZATION PROJECT MAC
Link to Website
National Government Services, Inc Novitas Solutions, Inc Wisconsin Physicians Service Insurance Corporation
http://www.ngsmedicare.com http://www.novitas-solutions.com http://www.wpsmedicare.com
Abbreviation: MAC, Medicare Administrative Contractor.
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Q: When should the HBO prior authorization be requested? A: The prior authorization should be requested as soon as the HBO treatment is scheduled. Q: Has CMS established a timeline for the MACs to respond to the HBO prior authorization requests? A: The MACs are supposed to make every effort to review the HBO prior authorization request and postmark decision letters within 10 business days. If the HOPD submits an expedited HBO prior authorization because the standard processing timeframe could jeopardize the life or health of the beneficiary, the MACs are supposed to make a reasonable effort to communicate a decision within 2 business days. If the initial prior authorization request was nonaffirmed, the HOPD can resolve the nonaffirmative reason described in the decision letter and resubmit the prior authorization request. The MACs are supposed to make every effort to review the resubmitted request and postmark decision letters within 20 business days. Note: Unlimited resubmissions are allowed for nonaffirmed prior authorizations, but these requests are not appealable. Q: Should HBO treatment be delayed until the prior authorization decision is made? A: The CMS has stated that HBO treatment should not be delayed because of a pending prior authorization and that an affirmed prior authorization decision will retroactively apply to the start date requested on the prior authorization request. Note: Claims should not be submitted to the MAC until the prior authorization decision has been received. Q: If the HBO prior authorization is not affirmed by the MAC, will the MAC explain why? A: Yes. The MAC will provide a detailed written explanation that will outline the specific policy requirement(s) that was/were not met. Q: Does the HOPD have any options if the HBO prior authorization request is not affirmed by the MAC? A: Yes, the HOPD has 2 choices: The HOPD can (a) resolve the specific HBO policy requirements that were not met and that were described in the MAC’s decision letter, and (b) resubmit the prior authorization request. The CMS allows unlimited prior authorization resubmissions. Note: Prior authorization request decisions are not appealable. The HOPD can provide the HBO therapy and submit a claim. The claim will automatically be denied. Note: All appeal rights will be available to the HOPD. Q: Once an affirmative decision is received from the MAC, how should the HOPD communicate that on their Medicare claim?
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A: The MAC’s affirmative decision letter will include the prior authorization unique tracking number (UTN), which the HOPD should submit on their claim. If the HOPD submits electronic 837 institutional claims, the UTN should be submitted at the 2300VClaim Information level in the Prior Authorization reference (REF) segment where REF01 = ‘‘G1’’ qualifier and REFO2 = UTN. If the HOPD submits paper CMS 1450 Claim forms, the UTN should be submitted in Form Locator 63. The UTN should be submitted on the same line (A, B, C) that Medicare is shown in Form Locator 50 (Payer Line A, B, C). The UTN should begin in position 1 of Form Locator 63. Q: What will happen if an HOPD in Illinois, Michigan, or New Jersey does not request HBO prior authorization, provides HBO therapy to a Medicare patient, and submits a claim to the MAC? A: When the MAC receives the claim, the MAC will stop the claim for prepayment review, send an Additional Document Request (ADR) to the HOPD, and wait 45 days for a response. Once the MAC receives the requested documentation, they will review it within 60 days. Q: Will the beneficiary be notified about the MAC’s prior authorization determination? A: Upon request, the beneficiary will be notified whether Medicare will pay for the HBO. Q: Are critical access hospitals or facilities included in this model? A: No. Critical access hospitals do not use the G0277 code and are not included in this prior authorization model. Q: Do qualified healthcare professionals (QHPs) need to request prior authorization from their MAC before they attend and provide supervision to HBO therapy performed in HOPDs? A: No. QHPs do not need to request MAC prior authorization. This nonemergent HBO therapy prior authorization project is only for the facility Medicare payment portion of the HBO therapy service. However, it is in the best interest of QHPs to check if the HOPD has received MAC prior authorization or a nonaffirmed MAC prior authorization. Reason: If the HOPD does not have a prior authorization or has a nonaffirmed prior authorization, the associated QHP claim with 99183 physician attendance and supervision of hyperbaric oxygen, per session will be subject to medical review. Q: Does CMS have any educational resources regarding the HBO prior authorization project? A: Yes, you can find a plethora of information (eg, fact sheet, frequently asked questions, background information, recordings and slides from CMS Open Door Forums) on the CMS website: http://go.cms.gov/PAHBO. In addition you can send questions to [email protected].
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