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Do physicians need to directly supervise hyperbaric oxygen therapy services (HBOT)? 

It is helpful to first review the definitions of the different types of level of supervision (CFR Title 42, Chapter IV, Part 410

  • (i) General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.
  • (ii) Direct supervision in the office setting means the physician must be present in the office suite and 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. During a public health emergency, as defined in § 400.200 of this chapter, the presence of the physician includes virtual presence through audio/video real-time communications technology when use of such technology is indicated to reduce exposure risks for the beneficiary or health care provider.
  • (iii) Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

2020 CMS Updates

In 2020, CMS changed the minimum required level of supervision from direct supervision to general supervision for all hospital-based diagnostic and therapeutic services provided by all hospitals and critical access hospitals, or CAHs (CY 2020 Medicare Hospital Outpatient Prospective Payment System Final Rule (CMS-1717-FC) 42 CFR §410.27(a)(1)(iv))

However, CMS pointed out that CAHs and hospitals in general continue to be subject to conditions of participation (CoPs) that complement the general supervision requirements for hospital outpatient therapeutic services to ensure that the medical services Medicare patients receive are properly supervised. CoPs for hospitals require Medicare patients to be under the care of a physician, and for the hospital to ‘‘have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital’’ (42 CFR 482.22). 

Under general supervision, the physician is still responsible for the care provided by nonphysician personnel. 

Failure of an applicable physician to provide adequate supervision in accordance with the hospital and CAH CoPs does not cause payment to be denied for that individual service. However, consistent violations of the CoP supervision requirements can lead to a provider having to establish a corrective action plan to address supervision deficiencies, and if the provider still fails to meet the CoP requirements, the hospital or CAH can be terminated from Medicare participation. 

Despite the update, CMS relies on safeguards that include allowing providers and physicians the discretion to require a higher level of supervision to ensure a therapeutic outpatient procedure is performed without risking a beneficiary’s safety or their quality of the care, as well as the presence of outpatient hospital and CAH CoPs, and other state and federal laws and regulations. 

Office-based reimbursement for CPT code 99183 (Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session (Professional Component Only)) still requires direct supervision.

ACHM and UHMS recommendations 

Both the American College of Hyperbaric Medicine (ACHM) and Undersea and Hyperbaric Medicine Society (UHMS) recommend that physicians continue to directly supervise HBOT. Standards of clinical practice should be maintained regardless of the updated supervision requirements. HBOT candidates often present with multiple comorbidities that justify the need for direct supervision.  

About the Authors

Elaine Horibe Song, MD, PhD, MBA
Dr. Song is a Co-Founder and Chief Executive Officer of WoundReference, Inc., a clinical and reimbursement decision support & telemedicine platform for wound care and hyperbaric clinicians. With a medical, science and business background, Dr. Song previously served as medical director for a regenerative medicine-focused biotech company in California, and for a Joint Commission International-accredited hospital network. Dr. Song also served as a management consultant for Kaiser Permanente, practiced as a plastic surgeon in private practice and academia, and conducted bench and clinical research in wound healing, microsurgery and transplant immunology. Dr. Song holds a position as Affiliate Professor, Division of Plastic Surgery, Federal University of Sao Paulo, and is a volunteer, Committee Chair of the Association for the Advancement of Wound Care. She has authored more than 100 scientific publications, book chapters, software registrations and patents.
Tiffany Hamm, BSN, RN, CWS, ACHRN, UHMSADS
An Advanced Certified Hyperbaric Registered Nurse and Certified Wound Specialist with expertise in billing, coding and reimbursement specific to hyperbaric medicine and wound care services. UHMS Accreditation Surveyor and Safety Director. Principal partner of Midwest Hyperbaric LLC, a hyperbaric and wound consultative service. Tiffany received her primary and advanced hyperbaric training through National Baromedical Services in Columbia South Carolina. In 2021, Tiffany received the UHMS Associate Distinguished Service Award
Jeff Mize, RRT, CHT, UHMSADS
Jeff is a Principal Partner with Midwest Hyperbaric LLC and is the Co-founder and Chief Clinical Officer for Wound Reference. Jeff is a Registered Respiratory Therapist, a Certified Hyperbaric Technologist (CHT) by the National Board of Diving and Hyperbaric Medical Technology, a Certified Wound Care Associate (CWCA) by the American Academy of Wound Management. After receiving primary hyperbaric training from National Baromedical Services he trained as a UHMS Safety Director and is a UHMS Facility Accreditation Surveyor. He is the 2010 recipient of the Gurnee Award and the 2013 recipient of the Paul C. Baker Award for Hyperbaric Oxygen Safety Excellence. He has also served on the UHMS Board of Directors (2010-2015) In 2020, Jeff received "The Associates Distinguished Service award (UHMSADS). "This award is presented to individual Associate member of the Society whose professional activities and standing are deemed to be exceptional and deserving of the highest recognition we can bestow upon them . . . who have demonstrated devotion and significant time and effort to the administrative, clinical, mechanical, physiological, safety, technical practice, and/or advancement of the hyperbaric community while achieving the highest level of expertise in their respective field. . . demonstrating the professionalism and ethical standards embodied in this recognition and in the UHMS mission.”
Eugene Worth, MD, M.Ed., FABA, ABPM/UHM
Eugene R. Worth, MD, M.Ed., FABA, ABPM/UHM is a board-certified anesthesiologist specialized in cardiac and vascular anesthesia. He is a wound care and hyperbaric physician, and Advisor/Editor of WoundReference, Inc., a clinical and reimbursement decision support platform for wound care and hyperbaric clinicians. Dr Worth is the recipient of a number of awards and distinctions in undersea and hyperbaric medicine. He has been a physician surveyor for the UHMS Accreditation Team and a reviewer for the journal, Undersea and Hyperbaric Medicine. He is a physician member of the UHMS Safety Committee. He has written multiple publications and book chapters for topics in hyperbaric medicine.
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