Brenda, I'll take a crack at this ... and I expect some backup opinions as well. The short answer to this question is ... "it depends." I like staying out of Medicare crosshairs, but I like doing what is best for the patient even better. So, let's get some answers to a couple of questions that I had as I read your query. The key to approval/denial for this is ENTIRELY driven by your documentation.
First, what type of radiation and the original diagnosis (I'm assuming prostate cancer, but you didn't say.)? Radiation for prostate cancer can be delivered by radioactive seeds, external electron beam radiation, and neutron beam radiation.
Where is the non-healed tissue located? This isn't a cheeky question, by any means. I need to know whether the bleeding tissue is in the bladder (distal trigone area) or in the prostatic urethra. This makes a huge difference. The most difficult to treat patients have 'hamburger' in their prostatic urethra. Friable, non-viable, easily bleeding. And, these are the patients with the most proclivity to have scar tissue form with need for further procedures to enhance urinary flow.
Next, the Virginia Mason Clinic analyzed their soft tissue radionecrosis patient for "skipped treatments" and found out that patients receiving at least 3 treatments per week had the same outcome as those who had 5 treatments per week. I never shared that with patients, but it was comforting to me to know that their outcomes were similar when patients had to miss HBO treatments. After all, I couldn't expect to control all of the patients' social calendars just to have them come visit our clinic ... tongue in cheek here ...
It seems to me that Medicare is hung up on 40 treatments as the "total dose." However, most radiation cystitis papers show rates closer to 60. My policy was to administer 40 treatments and stop for 30 - 60 days. Then have the urologist scope the patient and document the amount of friable or bleeding tissue. With this documentation in hand, I could write a note that took that information and laid the groundwork for another 20 treatments. You are already at 60 treatments and still have some episodic bleeding. Hmmm ... makes me wonder if this patient had neutron beam radiation. Those particles are larger than electron beam and creates much more collateral damage. Nevertheless, you can see that documentation and having data from direct observation from the surgeon gives you grounds to ask for another 20 treatments. You can also document the excellent response to date of the previous treatments.
OK, that's your homework. Tina and Jeff might have some other ideas about coding, but I will stick with the fact that a well documented note staves off fraud and abuse investigations and shows excellent medical decision making. Good luck.
gene worth
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