INTRODUCTION

Clear and concise medical record documentation is critical to providing patients with quality care and is required in order to receive accurate and timely payment for furnished services. Medical records chronologically report the care a patient received, including pertinent facts, findings, and observations about the patient’s health history. Medical record documentation helps physicians and other health care professionals evaluate and plan patients' immediate treatment and monitor their health care over time.[1]  

The hyperbaric progress note is to be completed daily by the provider who is directly supervising the treatment. The signed progress note not only proves direct supervision but substantiates the level of work required when billing hyperbaric oxygen therapy (HBOT) services. The progress note should stand on its own in the event of an insurance audit.  Countersigning nursing notes does not meet the Centers for Medicare & Medicaid Services (CMS) documentation requirements for Hyperbaric Oxygen Therapy billing (CPT code 99183 – "Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session or G0277 Hyperbaric Oxygen under pressure, Full body, Per 30 minute increment"). 

CMS has provided guidelines for documentation of HBOT services and expects that providers will follow its requirements. The following consultation template will assist providers with progress notes requirements for HBOT. This template is for reference only and all data contained within is purely hypothetical. 

DOCUMENTATION FOR HYPERBARIC OXYGEN THERAPY

HBOT progress notes should indicate:  

• Patient identification (name, medical record number, date of birth, age)
• Date of service
• Indication for treatment with HBOT (e.g. "radiation cystitis with hematuria")

Subjective

• History of present illness (HPI) (i.e., history of the indication that led to HBOT, and patient's tolerance and adherence to previous HBOT sessions so far)

Objective

• Vital signs 
• Allergies
• Transcutaneous Oximetry or other non-invasive tests, as indicated 
• Patient active problem list (diagnoses)

Assessment

• Review of systems (see topic "Documentation: HBO Consultation History and Physical")
• Physical exam (see topic "Documentation: HBO Consultation History and Physical")
• Documentation which describes the physical findings and relevance related to the condition being treated (i.e. what do you see? What is the condition of the wound, graft or flap, or irradiated tissue? Are there visible dental issues in osteoradionecrosis patients? Are there any complicating factors such as infection, pain, barotrauma, nutritional issues, hematuria, fibrotic tissue?)
• Pre Procedure Ear exam (see topic "Ear Exam - Barotrauma")
• Impression
• Documentation should include impression of indication being treated (e.g., "1. Other specified disorders of the skin and subcutaneous tissue related to radiation, 2. Irradiation cystitis with hematuria"),
• Assessment of the level of Progress made towards established therapy goals:
• CMS states progress must be addressed minimally every 30 days. We suggest progress be assessed and documented weekly. The daily note should make reference to the upcoming date progress will be assessed
• Examples of progress include but are not limited to angiogenesis in the wound bed, epithelial growth, decreased wound size, drainage, erythema or drainage. Decreased hematuria, demarcation of compromised graft and flaps or % of salvageable tissue, TCOM demonstrating improvement in tissue hypoxia i.e., peri-wound TcPO2 values > 40 mmHg
• Documentation supporting the threatened loss of function, limb or life

Hyperbaric Medicine Order

Orders should include the information below. For HBOT orders specific to each indication, see "HBO Physician Orders Overview"

• Treatment depth in ATA
  
• Treatment length of breathing 100% oxygen in minutes
• Frequency and length of air breaks

Sample statement for a HBOT order: 

• 2.5 ATA x 90 minutes of 100% oxygen breathing 
• 2 ten minute air breaks after every 30 minutes of 100% oxygen breathing and PRN
• 30 HBO treatments pre-surgical intervention and 10 HBO treatments post-surgical intervention to total 40

Encounter procedures

Procedure documentation should include: 

• Treatment depth in ATA
• Treatment length of breathing 100% oxygen in minutes
• Frequency and length of air breaks
• Air breaks - include start and stop times
• Rate of compression (descent) and decompression (ascent)
• Time left surface, Time reached pressure, Time left pressure, Time reached surface
• Actual bottom time
• Total treatment time
• Patient was treated in a hard-sided acrylic chamber
• Post procedure ear exam (see topic "Ear Exam - Barotrauma")
• Confirmation of direct supervision of HBOT treatments by a qualified healthcare professional 

• Effect of treatment on the patient:

  • How did the patient tolerate compression and decompression?
  • How is the patient managing the treatment in relation to the indication being treated?
  • Were there any signs of oxygen toxicity, hypoglycemia, anxiety?
  • Did the provider intervene for patient seizure, hypoglycemia or emergent procedure?

Sample statement describing the Procedure:

• Procedure

• Treatment depth 2.5 ATA
• Descent rate: 2 psi/min
• Time left surface
• Time arrived at pressure
• Air break 1: start 10:25am, stop 10:35am
• Air break 2: start 11:05am, stop 11:15am
• Time left pressure
• Time arrived at surface
• Ascent rate: 2 psi/min
• Actual Bottom Time: 110 minutes 
• Total Treatment Time: 132 minutes
• Post Procedure Ear Exam: no pain or other complaints, normal tympanic membrane without evidence of injury

The patient was placed inside a hard-sided acrylic hyperbaric chamber that is pressurized to greater than sea level pressure while breathing 100% oxygen. I was in attendance for the dive in its entirety. There were not untoward complications or complaints. The patient tolerated the treatment without problems and was discharged in stable condition and will return as scheduled to continue the treatment plan.

Plan of care

• Type of HBOT indication and protocol
• Laterality and anatomical location for the condition being treated 
• Anticipated timeline of therapy (e.g. "the patient will be treated Monday - Friday")
• Estimated number of treatments (e.g., 20, 30, 40 HBOT sessions) and current treatment number (e.g. "today is treatment number 3 of 40 total treatments")

Documentation identifying the plan of care for the course of treatment

• Daily plan of care can NOT be documented "continue protocol"

Documentation of interventions or adjunctive therapies as applicable 

• Pending labs, imaging or tests (MRI, CT, Vascular)
  
• Pending follow up with a specialist (ENT, Infectious Disease)
• If no pending tests, make a statement confirming that there are no tests pending
• Patient is being treated with negative pressure wound therapy (NPWT) during HBO
• Patient requires debridement post or pre HBOT

Sample Plan of Care statements:

• Daily hyperbaric oxygen treatments at 2.0 ATA  for 90 minutes of oxygen breathing at pressure to continue to 20 treatments at which time a TCOM will be performed to measure tissue hypoxia. Patient to follow up weekly in the wound clinic for wound evaluation and progress.
• Daily hyperbaric oxygen treatments at 2.0 ATA  for 90 minutes of oxygen breathing at pressure to continue to 30 treatments. The site of the infection will continue to be monitored daily and follow up with the referring provider scheduled for "state date".
• Daily hyperbaric oxygen treatments at 2.5 ATA  for 90 minutes of oxygen breathing at pressure to continue to 30 treatments. Follow up with Oral surgeon next week "state date". The decision will be made regarding future surgical revision date for ORN of the mandible
• Daily hyperbaric oxygen treatments at 2.0 ATA  for 90 minutes of oxygen breathing at pressure to continue to 30 treatments. Where clinical improvement is seen, the present regimen of antibiotic and HBOT should be continued for 4-6 weeks. Hyperbaric oxygen treatments continue until a good granulation bed has formed and no clinical signs of osteomyelitis are present. Patient to follow up with infectious disease "state date

Documentation of Advanced Beneficiary Notice if applicable

• For Medicare patients who are being treated for Central Retinal Artery Occlusion, Idiopathic Sudden Sensorineural Hearing Loss, or Prophylaxis for Osteoradionecrosis of the mandible, an ABN must be completed, signed by the patient and incorporated into the chart prior to beginning HBOT as these conditions are not covered on CMS' National Coverage Determination 20.29