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Medicare Coverage Determinations for Hyperbaric Oxygen Therapy

Medicare Coverage Determinations for Hyperbaric Oxygen Therapy

Medicare Coverage Determinations for Hyperbaric Oxygen Therapy

INTRODUCTION

To ensure proper Medicare reimbursement and smooth Medicare audits, clinicians must familiarize themselves with the Coding and Reimbursement guidelines for HBOT to ensure compliance with the Centers for Medicare and Medicaid Services. This topic provides a map of the Medicare Part A/B Medicare Administrative Contractors Jurisdictions and respective coverage determinations. For an Introduction to Hyperbaric Oxygen Therapy, see  An Introduction to Hyperbaric Oxygen Therapy  

NATIONAL OR LOCAL COVERAGE DETERMINATIONS

 The map below shows the Medicare Part A/B Medicare Administrative Contractors (MAC) Jurisdictions. MACs determine which types of interventions are covered along with documentation needed to justify medical necessity, utilization guidelines, frequency allowed, etc. Clinicians who bill Medicare should adhere to the guidance provided by their MAC to ensure proper reimbursement and smooth audits should they occur. 

Instructions

  • Find your state, and respective MAC (in the white bubble)
  • On the table below, find your MAC on the left column. The right column indicates if the MAC follows its own Local Coverage Determination (LCD) or if it follows the National Coverage Determination (NCD) 
  • To go to the NCD or LCD, click on the reference number (in blue brackets in the right column) and go to its reference page. On the reference page, click on the green button "View Source".
  • See details on requirements, medical necessity and documentation on specific Medicare National and Local Coverage Determinations

Medicare Administrative Contractor (MAC)  
National or Local Coverage Determination (NCD) (LCD)
Novitas Solutions, Inc. LCD Hyperbaric Oxygen (HBO) Therapy (L35021)[1]
CGS Administrators, LLC NCD 20.29 [2]
First Coast Service Options, Inc. (FCSO) LCD Hyperbaric Oxygen (HBO) Therapy (L36504)[3]
Noridian NCD 20.29 [2]
Wisconsin Physicians Service Insurance Corporation (WPS) NCD 20.29 [2]
National Government Services, Inc. (NGS) NCD 20.29 [2]
Palmetto  NCD 20.29 [2]

Local Coverage Determinations (LCDs) Development and Reconsideration Processes

All stakeholders are encouraged to participate in the LCD Process as well as the LCD Reconsideration Process. Recent regulations have made both processes transparent and open to everyone, including Medicare beneficiaries. For more information, consult the MLN Matters document on the topic MM10901.[4] 
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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. Novitas Solutions, Inc et al. Local Coverage Determination for Hyperbaric Oxygen (HBO) Therapy (L35021) . 2015;.
  2. CMS. National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29) . 2017;.
  3. First Coast Service Options, Inc. et al. Local Coverage Determination Hyperbaric Oxygen (HBO) Therapy (L36504) . 2016;.
  4. CMS Medicare Learning Network. Local Coverage Determinations (LCDs) - MM10901 MLN Matters. 2019;.
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