Checklist: Hyperbaric oxygen (HBO) therapy documentation
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for hyperbaric oxygen (HBO) therapy services. It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.
| Check | Documentation description |
|---|---|
| Documentation is for the correct beneficiary and date of service. | |
| Documentation is complete, legible, signed, and dated by the physician or clinician. | |
| Physician orders. | |
|
Initial assessment with complete history & physical examination:
|
|
| Documentation supporting Medicare coverage for NCD 20.29 requirements. | |
| Documentation must show standard wound care was provided and unsuccessful. | |
| Documentation of the procedure (logs) including ascent time, descent time and pressurization level. | |
| Documentation supporting the re-evaluation and effectiveness of treatment at least every 30 days (including wound evaluation) for response to therapy. | |
| Documentation to support physician-to-physician communications or records of consultations and/or additional assessments, recommendations, or procedural reports. | |
| Documentation to support any laboratory or radiology findings in support of HBO treatments. | |
| Documentation of date and anatomical site of prior radiation treatments and/or date of the skin graft and compromised state of graft site (if applicable based on treatment diagnosis). | |
| Documentation to support the patient’s condition and response to treatment warrant the number of services reported. | |
| Documentation to support an available trained emergency response team and ICU services during the treatment(s). | |
| Documentation must be legible, relevant, and sufficient to justify the medical necessity of services billed. | |
| Any applicable ABNs (advance beneficiary notice of noncoverage). |
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.