The Sky Is Blue, the Wind Blows as Air Heals

  • Gretchen Dixon, MBA, RN, CCS, CPCO, AHIMA Approved ICD-10-CM/PCS Trainer
  • Volume 07 - Issue 3

Does your clinical documentation support the medical necessity for hyperbaric oxygen services?

The Hyperbaric Oxygen (HBO) Therapy Services Webinar provides detailed information on clinical documentation, ICD-10-CM (diagnosis) code selection and billing for this service. Due to the amount of information, the webinar is broken into three parts with the understanding of time constraints and for the convenience of the audience. Upon completion of the webinar, a self-assessment quiz is provided as a measurement of understanding this topic. After obtaining a satisfactory score from the quiz, you will be awarded either CMEs or CEUs.

This three-part webinar series will provide the audience with clinical documentation and coding details through the following objectives:

  • Emphasize the need for detailed clinical documentation supporting medical necessity for HBO treatment by diagnosis.
  • Recognize the complexity assigning ICD-10-CM codes.
  • Review the common diagnoses covered by third-party payers.
  • Understand the specific elements in treatment documentation to support billing of services.
  • Be aware of anticipated or updated changes in the HBO treatment industry.

The following text are excerpts from the webinar with a few slides sharing the depth of information you will take away and be able to implement in real time on your next HBO clinical documentation improvement. You will also learn how to select the most accurate diagnosis code.

Documentation Principles

Slide 1 “Documentation Principles” identifies four key points for accuracy and clarity of clinical documentation details. Keep in mind the phrase “THINK-N-INK” when providing clinical documentation while watching for electronic health record “note bloat,” otherwise known as junk verbiage. Often today our electronic health records (EHRs) lack an individualized patient’s progress story from visit to visit. This includes the overused activity within the EHR option of copying/pasting irrelevant clinical documentation from past visits into the present visit.

How familiar are you with the annual updates to the Official Guidelines for Coding and Reporting with a specific focus on outpatient services and the use of uncertain terms for a diagnosis? Verbiage such as “I think,” “maybe,” “thought to be related to,” “depends” and “possibly” are some terms that denote doubt or uncertainty in the mind of the provider. Such terms cannot be coded as if they exist in the outpatient arena per Section 4, Diagnostic Coding and Reporting Guidelines for Outpatient Services; Subsection H: Uncertain Diagnosis.

Documentation Principles = THINK-N-INK
  • Provide accurate and detailed documentation in the HBO evaluation
    • Reason for the encounter or Chief Complaint provides the medical necessity by beginning the patient's story.
  • Educate all health care documenters to ensure the patient's wound progress, response to and changes in treatment or revision in diagnosis is accurately documented
  • Identify Risk
    • Change curve: add why the service is needed through clinical documentation details to eliminate vagueness
    • Weak documentation results in unspecified or weak ICD-10-CM codes
  • Teach / mentor providers what is permissible according to the Official ICD-10CM Guidelines for Coding and Reporting of Outpatient Services.

HBO and Prior Authorization

HBO therapy services provided to patients has entered into a period of intense monitoring involving prior authorization from both Centers for Medicare and Medicaid Services (CMS) and third-party payers. This is due to the investigative reports from the Office of Inspector General (OIG) at the request of CMS who identified high potential concerns regarding medical necessity and improper payments regarding Medicare beneficiaries.

Although the OIG report was for the calendar year 2000, the data noted approximately $14 million out of $50 million was paid in error for Medicare beneficiaries who received HBO therapy for noncovered medical conditions or the clinical documentation did not adequately support the medical necessity of the outpatient service. In addition, approximately $5 million was paid for treatments considered to be excessive. HBO therapy is now on the big map of medical service scrutiny.

Based on these findings, CMS instituted a Non-Emergent Hyperbaric Oxygen Therapy Prior Authorization Model implemented in three states in 2015. The OIG selected Illinois, Michigan, and New Jersey for the initial implementation of the model due to the two identified issues of high utilization and improper payment reimbursement.

Physician Evaluation Components

Initially, six diagnoses were listed for prior authorization; on December 28, 2015, however, CMS removed preparation and preservation of compromised skin grafts from the list. This webinar discusses in depth the specific clinical documentation details that support the medical necessity for HBO therapy.

Slide 2 provides the audience two areas of weaknesses often found in the medical record history components of Chief Compliant and History of Present Illness clinical documentation. Does your patient’s HBO evaluation include detailed clinical documentation? This webinar discusses each item in detail with real chart examples of accurate and inaccurate clinical documentation.

General Clinical Documentation Requirements
History Component includes:
  • Chief Compliant (CC) / Reason for the visit stated in the patient's own words
  • History of Present Illness (HPI)
    • Include the specific 8 elements which provide details to questions the provider asks the patient
      1. Location: Identify the site of the problem or symptom
      2. Context: Events describing the problem
      3. Duration: How long has the problem/condition existing?
      4. Quality: Describe or provide the characteristics of the problem
      5. Severity: What is the intensity, degree of the problem or symptom
        • Pain: rate of a scale of 1-10, describe the pain: stabbing, shooting, dull, sharp, etc.
      6. Timing: Regularity of occurence when the problem occurs
      7. Modifying factors: What factors have been attempted to relieve / exacerbate / not impact the problem?
      8. Associated signs and symptoms: other information details related to the reason for the encounter but does not fit in the other categories

Osteoradionecrosis and Radionecrosis

Clinical documentation is often vague with limited details of the patient’s past cancer treatments. A frequently used diagnosis is “radionecrosis of___ (body part)” with ICD-10-CM code T66 selected. When reviewing the ICD-10-CM Coding Manual Tabular List of Diseases and Injuries there is an exclude item that directs the coder to another code selection. Without knowing the specific steps on how to manually select an ICD- 10-CM (diagnosis) code but relying on the EHR Problem List, the selected code may not be the most accurate code for the HBO evaluation encounter. In this webinar we discuss the specific steps of selecting an ICD-10-CM code using real cases. Slide 3 provides an excerpt from an ICD-10-CM Coding Manual for the code T66. How often have you selected this ICD-10-CM code? Does it feel right, or do you have doubt?

Osteoradionecrosis & Radionecrosis
Trouble Finding Codes in ICD-10-CM
Step 2
In the ICD-10-CM Coding Manual turn to the Tabular List of Disceases and Injuries
  • T66 - Radiation sickness, unspecified
    • Excludes1 specified adverse effects of radiation, such as:
      • Excludes1 means "NOT CODED HERE"
        • burns (T20-T31)
        • leukemia (C91-c95)
        • radiation gastroenteritis and colitis (K52.0)
        • radiation pneumonitis (J70.0)
        • radiation related disorders of the skin and subcutaneous tissue (L55-L59)
        • radiation sunburn (L55.-)


Learn more by joining this three-part series on Hyperbaric Oxygen Therapy Services: Documentation, ICD-10-CM Coding and Billing Services at http://woundeducationpartners. com/online-courses/browse-course-list.html. You will challenge yourself to improve your clinical documentation and select more accurate diagnosis codes both supporting medical necessity and providing a defendable medical record for the services provided. The user-friendly information will improve your understanding of the coding applications, may provide answers to many of your coding questions, and reinforce your current knowledge of this topic.

At the end, you should have a clarified understanding of the value these sessions offer for those working in the wound- care environment. Mitigating possible denials or claim holds through accurate, clear, detailed, and cohesive clinical documentation is vital to ensure there is an even flow of revenue for services provided. Also, your improved clinical documentation provides a level of granularity and specificity for an accurate ICD-10-CM diagnosis(es) code(s), which supports the reason for the services provided to the patient.

There is a must for understanding the specific application of the current year’s Official Guidelines for Coding and Reporting Outpatient Services as it relates to the bottom line of your department’s operations. References are included for your personal library.


CMS Open Door Forum February 3, 2015, on Prior Authorization for HBO Therapy: Data-and-Systems/Monitoring-Programs/Medicare-FFS- Compliance-Programs/Prior-Authorization-Initiatives/ Downloads/HBO_PriorAuthSlides_ODF020314.pdf

CMS Prior Authorization for HBO Fact Sheet: https://www. Programs/Medicare-FFS-Compliance-Programs/Prior- Authorization-Initiatives/Downloads/HBOPriorAuth_ ExternalFAQ_122815.pdf

CMS Prior Authorization for HBO Fact Sheet: https://www. Programs/Medicare-FFS-Compliance-Programs/Prior- Authorization-Initiatives/Downloads/HBOPriorAuth_ ExternalFAQ_122815.pdf

Blue Cross and Blue Shield of Mississippi HBO Policy: policy-search.html&action=viewPolicy&path=%2Fpolicy%2Femed%2FHyperbaric+Oxygen+(HBO)+Pressurization.html

Blue Cross and Blue Shield of California HBO Pre-Authorization Policy: forms-lists/prior-auth-list.sp

Humana Commercial Preauthorization and Notification List January 18, 2016: documents.asp?file=2772055

Novitas Solutions, Medicare Prior Authorization for New Jersey: Optum 2016 ICD-10-CM Clinical Documentation Improvement Desk Reference


About the Author


GRETCHEN DIXON, MBA, RN, CCS, is the owner of Professional Compliance Strategies (PCS), LLC, and consults on outpatient departments and physician services. She has provided revenue- cycle compliance audits of services with a focus on wound care department operations for more than 10 years. She holds several credentials including an MBA in healthcare management, an RN with a practicing license in New York, and 23 multistate licensure from Virginia, AHIMA Certified Coding Specialist (CCS), AHIMA ICD-10-CM/PCS Approved Trainer, and is an AAPC Certified Professional (Healthcare)

Compliance Officer. A longtime internal healthcare auditor, Dixon identifies issues through audits of D, C, B (documentation, coding and billing) of provided services. The outcome of each audit determines the topics of education to be provided to the staff and physicians, as she proactively believes education is the key to having complete, accurate, and consistent documentation supporting reimbursement for billed services. If you are interested in her services, contact Dixon at This email address is being protected from spambots. You need JavaScript enabled to view it. or call 1-615-210-7476.


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