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HBO Initial Patient Evaluation

HBO Initial Patient Evaluation

HBO Initial Patient Evaluation


Justifying medical necessity for the use of hyperbaric oxygen therapy (HBOT) depends entirely on documentation in the patient's medical record. Documentation must provide an adequate description of the medical problem requiring the use of hyperbaric oxygen. A reasonable person should be able to read the documentation and conclude that the case merits use of this intervention. Success of your hyperbaric therapy unit requires compliance with applicable Federal and State laws, regulations, and the Undersea and Hyperbaric Medical Society (UHMS) treatment guidelines. In addition, developing and implementing clinic guidelines that detail the type of documentation required in accordance with insurance payers is fundamental.


The recommendation by a provider for the utilization of Hyperbaric Oxygen Therapy (HBOT) must include an initial evaluation that identifies, and accurately describes, the diagnosis or medical condition supporting the use of HBOT. The documentation should include information that supports use as reasonable and medically necessary. 

  • The initial evaluation identifies any underlying medical conditions that predispose patients to the side effects of HBOT. Potential side effects and adverse outcomes of HBOT must always be weighed in the context of the potential benefits. 
  • We recommend that the initial evaluation be a separate progress note or dictation in your medical record system, so that it can be made available to your insurer/payor upon request. This document must clearly illustrate the medical decision-making process before starting HBOT. We do not recommend this document to be an addendum to a clinic visit note or wound evaluation note. This is a separately identifiable visit with appropriate evaluation and coding.

Documentation to establish the medical necessity for hyperbaric oxygen therapy should include all of the following: (also see" HBO Documentation Checklist"):

  • An initial assessment that includes a detailed history and physical examination, clearly describing the condition(s) for which HBOT is recommended and identifying any physical signs that support the therapy planned (e.g., radiation tattoos or visible chronic radiation damage).
  • Documentation must include a description of the events leading to onset of the condition, any pertinent diagnostic reports, wound measurements, and any applicable medical/surgical treatment provided.
  • Organize the initial consultation note on a timeline from the onset of symptoms and follow events chronologically to the time that HBOT is recommended.
  • Documentation of previous treatment modalities by a referring provider.
  • Documentation of laboratory, pathology, radiologic, and/or vascular studies that support any adjunctive therapy provided to the patient in the treatment of the diagnosed condition.
  • Include pertinent operative and/or procedure reports related to the diagnosis (if applicable); dates, dose, modality and anatomical site of any radiation treatments (if applicable); and any prior antibiotic administration records to support chronic refractory osteomyelitis (if applicable).
  • In the case of non-healing wounds/ulcers, documentation of potential causes of delayed wound healing should be clearly identified 
  • Evaluation of the need for pressure relief and offloading modalities (if applicable)
  • Evaluation of vascular status (if applicable), including results of tests and interventions 
  • Evaluation of nutritional status (if applicable), diabetes management, and medication adjustments
  • Evaluation of signs/ symptoms of wound infection (if applicable)
  • Documentation of hyperbaric oxygen therapy risk assessment. Specifically identify underlying medical conditions that may predispose patients to the side effects associated with HBOT. For more information, please see Hyperbaric Chamber History and Consent"
  • Include evidence demonstrating HBOT patient education. 
  • The hyperbaric physician order should clearly state the indication for HBOT and the recommended treatment protocol. This includes all of the following:
    • Treatment pressure (e.g. 2.0 ATA).
    • Duration of oxygen breathing during each treatment (e.g. 100% oxygen for 90 minutes)
    • Number and duration of air breaks (if appropriate)
    • Estimated number of treatments
  • Include any documentation of interventions or collaboration with other providers in this patient's care plan (e.g. laboratory tests, medications, radiologic studies, and referral to specialist).

Pre-determination or prior authorization is required for Hyperbaric Oxygen Therapy treatment by many insurance carriers, including some Medicare fiscal intermediaries. Please see " HBO Pre-Determination/ Prior Authorization". 

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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.
Topic 843 Version 1.0


Hyperbaric Oxygen Therapy Consultation Intake Questionnaire

Consultation Template for Hyperbaric Oxygen Therapy

Consultation template to assist providers with progress notes documentation requirements for HBOT

Risk and Benefit Assessment for Hyperbaric Oxygen Therapy

To ensure audit-readiness and smooth reimbursement, facility and physician charges related to wound care and hyperbaric oxygen services must be validated with documentation from both physician AND non-physician providers (i.e.,Certified Hyperbaric Registered Nurses and Certified Hyperbaric Technologists). The CHRN or CHT note is proof and validation that a treatment was provided and billed by the facility (G0277). This topic provides a template for hyperbaric treatment records documented by non-physician providers.

Hyperbaric Oxygen Patient History and Consent