CMS HBO Non-Emergent Denial Reason Codes and Statements

Last updated on 2/17/21 | First published on 7/1/19 | Literature review current through Apr. 2025 [cite]

Authors: Tiffany Hamm BSN, RN, CWS, ACHRN, UHMSADS, more...

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]

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Type of code	Reason Code	Description
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
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.
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.
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.
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.

Showing 1 to 50 of 86 entries

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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

Topic 1373 Version 1.0

5/5/2025 1:01:11 AM

CMS HBO Non-Emergent Denial Reason Codes and Statements

CMS HBO Non-Emergent Denial Reason Codes and Statements

INTRODUCTION

CMS HBO DENIAL REASON CODES

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