Background

Definitions

• Related to supervision of medical services by providers  [1][2]:
• General supervision: means that the procedure or service is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure (42 CFR 410.32(b)(3)(ii)).[1]
• Direct supervision: direct supervision means that the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed (42 CFR 410.32(b)(3)(ii)).[1]
• Personal supervision: personal supervision means that the physician must be in attendance in the room during the performance of the service or procedure (42 CFR 410.32(b)(3)(iii).[1]
• Immediate availability: "immediately available" is defined as being in close physical proximity within the same building or connected building or structure, to where HBO treatments are provided and able to personally and physically attend to the chamber-side as soon as requested.[3]
• Related to physician services included in CPT code 99183 "Physician attendance and supervision of hyperbaric oxygen therapy, per session" [4][5]:
• The code is reported for physician attendance of each session of hyperbaric oxygen therapy, and includes evaluation and management (E&M) services related to HBOT. 
• E&M services integral to HBO therapy, according to Medicare Administrative Contractor (MAC) Noridian: E&M services integral to HBO therapy include, but are not limited to, updating history and physical, examining patient, reviewing laboratory results and vital signs with special attention to pulmonary function, blood pressure, and blood sugar levels, clearing patient for procedure, monitoring and/or assisting with patient positioning, evaluating and treating patient for barotrauma and other complications, prescribing appropriate medications, etc.[4]
• Any services and/or procedures provided in addition to the physician attendance and supervision (e.g, E & M services, wound debridement, transcutaneous PO2 determinations) in the hyperbaric oxygen treatment facility, in conjunction with hyperbaric oxygen therapy should be reported separately. 
• See current fee schedule in topic "HCPCS/CPT Codes and Physician Fee Schedule Commonly Utilized in Wound Care and HBOT".

• Related to Facility charge for technical service G0277 "HBO under pressure, full body chamber, per 30-minute interval".[4]

  • See current fee schedule in topic "Chargemaster Template for Hospital Outpatient Wound Care Services"

Relevance

For hospital outpatient departments (place of service or POS 19 and 22): 

• CMS' change in the supervision requirements related to Outpatient Therapeutic Services Incident to a Physician’s Service: since 2020, CMS expects the provision of all therapeutic services to hospital outpatients to be under general supervision by an appropriate physician or non-physician practitioner, including Critical Access Hospital (CAH) outpatients.[2][6] Along with this change in supervision requirement from direct to general supervision, CMS emphasized that [2][6]:
• 1) Establishing general supervision as the default level of physician supervision for outpatient therapeutic services does not prevent a hospital or CAH from requiring a higher level of supervision for a particular service if they believe such a supervision level is necessary, and
• 2) Providers and physicians have flexibility to require a higher level of physician supervision for any service they furnish if they believe a higher level of supervision is required to ensure the quality and safety of the procedure and to protect a beneficiary from complications that might occur.
• Reasons for change in supervision requirements: CMS' decision to change in supervision requirements from direct supervision to general supervision was influenced by several factors [2]:
• Challenges Faced by Rural Hospitals: Direct supervision, which necessitates a physician or non-physician practitioner to be immediately available (but not physically present) during the service, posed significant challenges to CAHs and small rural hospitals. These institutions often faced difficulties in meeting the direct supervision requirement due to physician and non-physician practitioner shortages.
• Non-Enforcement and Policy Consistency: Since 2009, CMS or Congress had been extending non-enforcement of the direct supervision standard for CAHs and small rural hospitals. This created uncertainty and operational challenges for these hospitals. The shift to general supervision was aimed at standardizing the requirements across all hospitals and CAHs.
• Ease of Monitoring and Enforcement: The change to a uniform level of supervision across all hospitals is easier for CMS to monitor and enforce. It also acknowledges the difficulty and inefficiency in auditing and monitoring safety and supervision of all therapeutic services through hospital payment systems.
• Impact on HBOT services: It is important to note that for specific services like HBOT services, despite the change in supervision level under the Outpatient Prospective Payment System (OPPS) to “general”, CMS still expects that code G0277 be billed for Facility Services and CPT code 99183 be billed for Physician Services, for any given HBOT service provided to a patient.[4] 

For Doctor's/Qualified Healthcare Provider's Offices (POS 11):

• CMS' change in the supervision requirements as described above only applies to Outpatient Therapeutic Services under the Hospital Outpatient Prospective Payment System (OPPS) (POS 19 and 22). For HBOT services supplied at doctor's office, direct supervision is still required by CMS.  

For both HOSPITAL OUTPATIENT DEPARTMENT and Doctor's office

• Undersea & Hyperbaric Medical Society (UHMS) Guidelines: Regardless of place of service, according to the UHMS Guidelines for Credentialing, Privileging and Supervision of Hyperbaric Oxygen Therapy in the U.S.A., "the attending MD/DO or advanced practice provider shall remain immediately available during all phases of hyperbaric treatment, defined as whenever patients are in the chamber under pressure and the door is closed. ‘Immediately available’ is defined as being in close physical proximity within the same building or connected building or structure, to where HBOT services are provided and able to personally and physically attend to the chamber-side as soon as requested."[3]
• The Joint Commission: The statement above should also be applicable to facilities accredited by the Joint Commission (TJC), as UHMS is recognized by TJC as a complementary accrediting organization, through a cooperative agreement initiative.[7] 
• Commitment to higher-quality care and mitigation of medico-legal and audit risks: Direct supervision in HBOT is critical for patient safety, especially considering that patients undergoing HBOT often have multiple serious comorbidities and are on numerous medications. This complexity increases the risks associated with HBOT, necessitating the presence of a well-trained hyperbaric physician. Studies have shown that hyperbaric patients typically have an average of 10 comorbidities and take around 12 medications, highlighting the need for careful medical oversight.[8] Furthermore, data indicates that physicians generally supervise a limited number of HBOT sessions per day, averaging around 3.6 to 5.4 treatments.[8][9] This low number suggests that simultaneous supervision of multiple hyperbaric patients is rare in the US, underscoring the importance of focused, direct physician involvement in each session.[9]

POLICY

To clarify the requirements and responsibilities of supervision for physicians, non-physician providers and all members of the wound care and hyperbaric medicine department. The policy is intended to establish the operational requirements and processes when hyperbaric oxygen therapy (HBOT) supervision is provided.  This includes describing the timeline and requirements for being immediately available, as well as meeting the documentation requirements for the provider(s) and clinical staff.

Background

• An institutionally credentialed hyperbaric physician or qualified healthcare provider is required to evaluate every patient referred to the Hyperbaric Medicine Service. Recommendations will be developed and provided to the referring physician. If hyperbaric oxygen therapy is deemed suitable, a treatment plan following the Hyperbaric Treatment Protocol Guidelines will be initiated. Unless specified otherwise, patients will continue to be under the care of their primary/referring physician(s).
• While we recognize that CMS no longer requires “direct” supervision for hyperbaric oxygen therapy in the hospital outpatient department, “direct” supervision is still required in the office. Additionally, the UHMS recommends that all providers who supervise hyperbaric oxygen therapy practice “direct” supervision.[3] Finally, the current CPT descriptor for 99183, is for physician attendance and supervision, which would require at least “direct” supervision for each hyperbaric oxygen therapy treatment.[5]
• Physician or Qualified Healthcare Provider supervision is required for the provision of all hyperbaric oxygen therapy treatments. The physician or qualified healthcare provider must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the treatment. 
• Immediate Availability: The physician or qualified healthcare provider shall be immediately available during all phases of hyperbaric treatment, defined as whenever patients are in the chamber under pressure and the door is closed. ‘Immediately available’ is defined as being in close physical proximity within the same building or connected building or structure, to where HBOT services are provided and able to personally and physically attend to the chamber-side as soon as requested.[3]
• The physician or qualified healthcare provider must be knowledgeable about the therapeutic service and be clinically able to furnish the service. The supervisory responsibility is more than the capacity to respond to an emergency and includes the ability to take over performance of a procedure or provide additional orders.[2]

Providing Hyperbaric Oxygen therapy supervision, (hyperbaric oxygen therapy)

• HBOT supervision will be provided in accordance with the Undersea Hyperbaric Medical Society (UHMS) best practice guidelines which require: The physician or non-physician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure.[3]
• The physician or qualified healthcare provider will be knowledgeable about the therapeutic service and institutionally credentialed to provide the service.[3]
• The physician or qualified healthcare provider supervisory responsibility requires the capacity to respond to an emergency and includes the ability to take over performance of a procedure or provide additional orders. [3]
• The physician or qualified healthcare provider will be immediately available as defined by CMS: "without delay" meaning the supervising physician is or non-physician practitioner readily available and without delay, to assist and take over the care as necessary. 
• It is recommended that the physician or qualified healthcare provider be present during the pressurization and depressurization of the chamber.
• The physician or qualified healthcare provider is not required be present in the hyperbaric suite/ room for the entire treatment or within any other physical boundary as long as he or she is immediately available. [3]
• The physician or qualified healthcare provider is required to provide a written order for each hyperbaric treatment. 
• The physician or qualified healthcare provider must personally evaluate the patient prior to or at the conclusion of each HBOT to assess the patient’s response to treatment, the course of treatment, patients progress and when necessary, modify the plan of care. [4][5]
• Prior to initiating the therapeutic service, the nurse or ancillary personnel will confirm with the supervisory physician or qualified healthcare provider their presence and that he or she is readily available and without delay, to assist and take over the care as necessary.
• Prior to initiating the therapeutic service, the nurse or ancillary personnel will confirm the physician or qualified healthcare provider orders for the therapeutic service or procedure. 
• The physician or qualified healthcare provider must provide documentation and attestation of their presence and the provision of supervision of the HBOT procedure or service provided and a plan of care.

REVIEW/REVISION OF POLICY

This policy shall be reviewed and, if necessary, revised at least every year.

Policy Effective Date:

Reviewed Date:

Revised Date:

CREDENTIALING AND TRAINING GUIDELINES

• Medical Director Job Description
• Physician Credentialing Guidelines
• Physician Credentialing Privilege List
• Physician Training Guidelines
• Qualified Healthcare Professional Job Description
  
• Qualified Healthcare Professional Credentialing Guidelines