With ICD-10 Codes Tied to Covered Conditions, HBOT May Be Ripe for NCD Risk Assessment

With basketball season getting underway, legendary player LeBron James may be climbing into his hyperbaric oxygen chamber to promote the post-game healing process. Even if he were a Medicare beneficiary, that probably wouldn’t be a covered condition. Medicare coverage hinges on whether patients receive hyperbaric oxygen therapy (HBOT) for covered conditions spelled out in its national coverage determination (NCD Manual § 20.29, Hyperbaric Oxygen Therapy, Dec. 18, 2017), but compliance also depends on other requirements, including a related list of ICD-10 codes. Although in some ways the codes make establishing HBOT medical necessity black and white, their sheer volume and the fact they’re subject to change—as well as the challenges around documentation for diabetes and other covered conditions—make HBOT vulnerable to claim denials, an expert said.

HBOT is one example of the NCDs that put hospitals at compliance risk if their coding and/or documentation don’t match, said physician Arthur Petersen, president of Better Health Better Care and a former revenue cycle/compliance professional at Intermountain Healthcare in Utah. There are 345 NCD documents, which set forth the coverage conditions for certain procedures and services. Medicare administrative contractors (MACs) also put out their own versions—local coverage determinations (LCDs)—in some areas not addressed by NCDs or when they want to elaborate.

Petersen suggested hospitals conduct risk assessments of high-risk NCDs, such as HBOT, which has come under scrutiny (RMC 6/25/18, p. 1). “These NCDs are so intricate that Medicare created a spreadsheet for how the NCD works based on ICD-10 diagnosis codes and some procedure codes,” he said at an Oct. 15 webinar sponsored by the Health Care Compliance Association. In other words, CMS mapped the covered conditions in the NCD to ICD-10 codes “they determined are payable. If claims have the codes on them, they can pay the claims. If not, they will deny them outright.”

This document is only available to subscribers. Please log in or purchase access.


Would you like to read this entire article?

If you already subscribe to this publication, just log in. If not, let us send you an email with a link that will allow you to read the entire article for free. Just complete the following form.

* required field