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CMS HBO Non-Emergent Denial Reason Codes and Statements

CMS HBO Non-Emergent Denial Reason Codes and Statements

CMS HBO Non-Emergent Denial Reason Codes and Statements

INTRODUCTION

CMS contractors medically review some claims (and prior authorizations) to ensure that payment is billed (or authorization requested) only for services that meet all Medicare rules. If the review results in a denied/non-affirmed decision, the review contractor provides a detailed denial/non-affirmed reason to the provider/supplier. Services may be denied when individual case documentation reveals that specific coverage requirements are not met. The following links provide a list of all CGS medical review denial reason codes by provider type and the definition.
In 2015, The Centers for Medicare and Medicaid Service (CMS) began to standardize the reason codes and statements to help us better understand why claims were denied. If you deal with multiple CMS contractors, understanding the many denial codes and statements can be difficult.[1] This topic provides a list of current HBOT non-emergent reason codes and statements.[2]

CMS HBO DENIAL REASON CODES

Instructions: 1. To sort, click on the header of each column. To "search", use the search field. Source: CMS Non-Emergent Hyperbaric Oxygen (HBO) Therapy Reason Codes and Statements (Updated 7/3/17.[2]
Type of code Reason Code Description
Insufficient documentation/ General HBO1A  Documentation does not include history and physical along with any previous treatment (i.e.   antibiotic therapy, surgical interventions) for specified condition
Insufficient documentation/ General HBO1B  The documentation does not include a covered diagnosis per the NCD
Insufficient documentation/ General
HBO1C
Hyperbaric Oxygen (HBO) therapy treatment records not provided or did not include the ascent time, descent time, total compression time, dose of oxygen, pressurization level, documentation of attendance, and a recording of events.
Insufficient documentation/ General
HBO1D
The documentation did not include the diagnostic test that was referenced in the physician narrative to confirm diagnosis
Insufficient documentation/ General
HBO1E
Physician order including number of treatments and/or number of units not provided.
Insufficient documentation/ General
HBO1F
Process updates with responds to treatment with measurable signs of healing not provided. 
Insufficient documentation/ General
HBO1G
Documentation does not indicate the entire body was exposed to oxygen under increased atmospheric pressure.
Insufficient documentation/ General
HBO1H
Documentation does not include recent adjunctive therapy. 
Insufficient documentation/ General
HBO1I
Documentation of diagnostic test and/or labs not provided to support specified condition.
Insufficient documentation/ General
HBO1J
Documentation of surgical debridement of devitalized tissue was not provided. 
Insufficient documentation/ General
HBO1K
Documentation was not provided indicating the type of treatment or intervention started and/or completed to resolve an active infection.
Insufficient documentation/ Specific Conditions     
HBO2A 
There is no documentation that patient has acute carbon monoxide intoxication.   
Insufficient documentation/ Specific Conditions     
HBO2B
 There is no documentation that patient has decompression illness.
Insufficient documentation/ Specific Conditions     
HBO2C
There is no documentation that patient has a gas embolism.
Insufficient documentation/ Specific Conditions     
HBO2D
There is no documentation that patient has gas gangrene.
Insufficient documentation/ Specific Conditions     
HBO2E
There is no documentation that patient has acute traumatic peripheral ischemia.
Insufficient documentation/ Specific Conditions     
HBO2F
There is no documentation that adjunctive treatment was used in combination with accepted standard therapeutic measures when loss of function, limb or life is threatened for acute traumatic peripheral ischemia
Insufficient documentation/ Specific Conditions     
HBO2G
There is no documentation of crush injuries and suturing of severed limbs. 
Insufficient documentation/ Specific Conditions     
HBO2H
There is no documentation of adjunctive treatment when loss of function, limb, or life is threatened for crush injuries and suturing of severed limbs.
Insufficient documentation/ Specific Conditions     
HBO2I
There is no documentation that patient has progressive necrotizing infection (necrotizing fasciitis).
Insufficient documentation/ Specific Conditions     
HBO2J
There is no documentation that patient has acute peripheral arterial insufficiency.
Insufficient documentation/ Specific Conditions     
HBO2K
There is no documentation that patient needs preparation and preservation of compromised skin grafts.

Insufficient documentation/ Specific Conditions

HBO2K

There is no documentation that patient needs preparation and preservation of compromised skin grafts.

Insufficient documentation/ Specific Conditions

HBO2L

There is no documentation that patient has chronic refractory osteomyelitis.

Insufficient documentation/ Specific Conditions

HBO2M

There is no documentation indicating patient was unresponsive to conventional medical and surgical management for chronic refractory osteomyelitis.

Insufficient documentation/ Specific Conditions

HBO2N

There is no documentation that patient has osteoradionecrosis.

Insufficient documentation/ Specific Conditions

HBO2O

There is no documentation that treatment is an adjunct to conventional treatment for osteoradionecrosis.

Insufficient documentation/ Specific Conditions

HBO2P

There is no documentation that patient has soft tissue radionecrosis.

Insufficient documentation/ Specific Conditions

HBO2Q

There is no documentation that treatment is an adjunct to conventional treatment for soft tissue radionecrosis.

Insufficient documentation/ Specific Conditions

HBO2R

There is no documentation that patient has cyanide poisoning.

Insufficient documentation/ Specific Conditions

HBO2S

There is no documentation that patient has actinomycosis.

Insufficient documentation/ Specific Conditions

HBO2T

There is no documentation that treatment is an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment for actinomycosis.

Insufficient documentation/ Specific Conditions

HBO2U

There is no documentation patient has both type I or type II diabetes and a lower extremity wound that is due to diabetes.

Insufficient documentation/ Specific Conditions

HBO2V

There is no documentation patient has a diabetic wound classified as Wagner grade III or higher.

Insufficient documentation/ Specific Conditions

HBO2W

There is no documentation patient has failed an adequate course of standard wound therapy for diabetic wound management.

Insufficient documentation/ Specific Conditions

HBO2X

There is no documentation of initial and repeated wound measurements during 30 days of conservative treatment for diabetic wound management.

Insufficient documentation/ Specific Conditions

HBO2Y

There is no documentation addressing the patient's nutritional status for diabetic wound management.

Insufficient documentation/ Specific Conditions

HB2AA

There is no documentation that a clean, moist bed of granulation tissue with appropriate moist dressing was completed for diabetic wound management.

Insufficient documentation/ Specific Conditions

HB2AB

There is no documentation indicating the patient's vascular status was addressed for diabetic wound management.

Insufficient documentation/ Specific Conditions

HB2AC

There is no documentation indicating optimal glucose control for diabetic wound management.

Insufficient documentation/ Specific Conditions

HB2AD

There is no documentation indicating that the appropriate off-loading measures have been utilized for diabetic wound management.

Insufficient documentation/ Specific Conditions

HB2AE

There is no documentation indicating the type of treatment or intervention to resolve an active infection has been initiated for diabetic wound management.

Insufficient documentation/ Specific Conditions

HB2AF

There is no documentation indicating debridement of devitalized tissue was completed for diabetic wound management.

Insufficient documentation/ Specific Conditions

HB2AG

There is no documentation showing measurable signs of improvement of the diabetic wound after 30 days of Hyperbaric Oxygen (HBO) therapy.

Medical necessity

HBO3A

Documentation provided indicates less than 30 days of standard wound care treatment was completed for diabetic wound management.

Medical necessity

HBO3B

Diagnostic test provided does not confirm the diagnosis.

Medical necessity

HBO3C

The documentation for continued use of Hyperbaric Oxygen (HBO) therapy for the identified wound did not show measurable signs of improvement after 30 days of Hyperbaric Oxygen (HBO) therapy.

Medical necessity

HBO3D

The documentation did not support the diabetic wound to be a Wagner grade III or higher.

Medical necessity

HBO3E

The documentation supports there was measurable signs of healing to the wound with the use of standard wound care prior to the initiation of Hyperbaric Oxygen (HBO) therapy.

Medical necessity

HBO3F

Documentation indicates patient's vascular status was compromised but was not addressed.

Medical necessity

HBO3G

Documentation indicates patient is at nutritional risk but no education was provided regarding nutrition.

Medical necessity

HBO3H

The documentation does not indicate optimal glucose control has been achieved or attempted for diabetic wounds (i.e. medication management to include insulin or oral meds, routine glucose checks ordered).

Medical necessity

HBO3I

Documentation indicates an active infection is present and is not being treated.

Medical necessity

HBO3J

Documentation indicates there is devitalized tissue in the wound and debridement of this tissue was not completed.

Medical necessity

HBO3K

The submitted Diagnosis code(s) does not meet 1 of the 15 Covered Conditions based on the ICD-9/ICD-10 codes approved per Medicare’s National Coverage Determination (NCD) Guidelines.

Medical necessity

HBO3L

Documentation indicates patient was not tolerant of Hyperbaric Oxygen (HBO) therapy.

Medical necessity

HBO3M

The medical documentation does not support the medical necessity for Hyperbaric Oxygen (HBO) therapy, however, a valid Advance Beneficiary Notice (ABN) was submitted.

Medical necessity

HBO3N

The medical documentation does not support the medical necessity for Hyperbaric Oxygen (HBO) therapy, however, an invalid Advance Beneficiary Notice (ABN) was submitted.

Does not meet benefit

HBO4A

The electronic medical records are missing the physician's/practitioner's electronic signature and date.

Does not meet benefit

HBO4B

The treatment log is missing a valid signature.

Does not meet benefit

HBO4C

Documentation submitted was not legible.

Does not meet benefit

HBO4D

Documentation indicates a topical application of oxygen was used and this method of administering oxygen does not meet the definition of Hyperbaric Oxygen (HBO) therapy per the National Coverage Determination (NCD).

Does not meet benefit

HBO4E

The Hyperbaric Oxygen (HBO) therapy is denied as the documentation indicates the diagnosis is non-covered, however, a valid Advance Beneficiary Notice (ABN) was submitted.

Does not meet benefit

HBO4F

Hyperbaric Oxygen (HBO) therapy is denied as the documentation indicates the diagnosis is non-covered, however, an invalid Advance Beneficiary Notice (ABN) was submitted.

Hyperbaric Oxygen (HBO) therapy number of billed unit/ Incorrect coding MUE

HBO5A

The number of billed services is denied as it is considered medically unlikely for Hyperbaric Oxygen (HBO) therapy.

Billing

HBO6A

Date(s) of service on the documentation do not match the date(s) of service billed on the claim for Hyperbaric Oxygen Therapy.

Billing

HBO6B

The documentation indicated that the provider is billing "incident to" the supervising physician, however, the name of the physician is not documented in the medical records.

Billing

HBO6C

Claim service not covered by this payer/contractor. You must send claim to the correct payer/contractor.

Billing

HBO6D

This is a duplicate claim to another claim.

Billing

HBO6E

The medical records submitted do not match the beneficiary billed on the Hyperbaric Oxygen (HBO) therapy claim.

Billing

HBO6F

Beneficiary name does not match the Medicare number.

Billing

HBO6G

Number of units billed does not match treatment log.

Incorrect coding 

HBO7A

The provider billed the GA modifier for having a signed Advanced Beneficiary Notice (ABN) on file for services rendered, however, there was no
ABN submitted or the ABN submitted was invalid.

Order

HBO8A

Written physician/practitioner signed order not provided for Hyperbaric Oxygen (HBO) therapy.

Order

HBO8B

The signature on the physician/practitioner order was illegible and no signature attestation was submitted.

Order

HBO8C

Missing valid signature on the physician/practitioner order.

Order

HBO8D

Order provided does not indicate number of treatments.

Order

HBO8E

Order provided does not have patient name.

Order

HBO8F

Order provided is not dated.

Provider/Beneficiary Eligibility 

HBO9A

Billing provider does not match the rendering provider documented in the medical records.

Provider/Beneficiary Eligibility 

HBO9B

The supervising provider specialty is not certified to supervise Hyperbaric Oxygen (HBO) therapy.

Provider/Beneficiary Eligibility 

HBO9C

Beneficiary is not eligible for Medicare Benefits.

Provider/Beneficiary Eligibility 

HBO9D

The facility is not authorized or eligible to bill Medicare.

Provider/Beneficiary Eligibility 

HBO9E

The supervising provider is not authorized or eligible to bill Medicare.

Other

HBO0A

Documentation received does not support Hyperbaric Oxygen Therapy a letter will be forthcoming with additional information

Local Coverage Determination (LCD), National Coverage Determination (NCD) and articles for medical review

HB11A

The decision to deny is based on a Local Coverage Determination (LCD) or an Article (LCA) for medical review based on the National Coverage Determination (NCD) for Hyperbaric Oxygen (HBO) therapy. A copy of the policy/article and NCD is available at www.cms.gov/mcd. Or if you do not have web access, you may contact the contractor to request a copy of the LCD or article.

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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. CMS.gov. Review Reason Codes and Statements . 2018;.
  2. CMS.gov. Review Reason Codes and Statements: Hyperbaric Oxygen Therapy Non Emergent . 2017;.
Topic 1373 Version 1.0