The Medicare Administrative Contractor Palmetto recently released the results of a post payment probe for hyperbarics (HCPCS Code: G0277). We’ve seen this before within our industry and it usually means another round of audits are coming. Here’s a summary of the findings and how you can avoid hyperbaric denials through strong documentation practices:
A total of 285 claims were reviewed, where 144 of the claims were either completely or partially denied, resulting in an overall claim denial rate of 50.53 percent. The total dollars reviewed was $528,827.62, of which $225,654.86 was denied, resulting in a charge denial rate of 42.67 percent.
The Top Denial Reasons Were
“No Documentation of Medical Necessity” and “Recommended Protocol was not Ordered and/or Followed”
How to Avoid These Denials
Documentation that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:
- All documentation to support orders, documentation of services rendered and documentation of medical necessity for the qualifying services for the date(s) billed
- Clear physician’s order with indication of need, dose, frequency and route
- Date and time of associated chemotherapy, as applicable
- Relevant history and physical and/or progress notes
- Clear indication of the diagnosis
- Clinical signs and symptoms
- Prior treatment and response, as applicable
- Stage of treatment, as applicable
- Documentation of administration
The microscopic lens from CMS continues to focus on HBO and the care leading up to it. This is just one example of how we monitor the industry and keep our programs updated.