Hyperbaric Oxygen Checklist

Published 02/05/2025

Providers, you can use this Hyperbaric Oxygen (HBO) checklist checklist as an audit tool to help assure that you are submitting all required documentation. 

Hyperbaric Oxygen Therapy Checklist Yes No N/A
Is the documentation provided for the correct beneficiary?

 

 

 

Is the documentation provided for the correct dates of service?

 

 

 

Are the number and length of HBO treatments to be administered documented?

 

 

 

Does the documentation provided support the medical necessity for HBOT?

 

 

 

Does the medical record include progress notes updated every 30 days that support the patient’s response to therapy and measurable signs of healing?

 

 

 

Is the indicated diagnosis being treated with HBO covered by the NCD?

 

 

 

Are the radiology, pathology, or lab reports included to confirm the diagnosis of Chronic Refractory Osteomyelitis?

 

 

 

Is the wound classified as Wagner Grade III or higher?  

 

 

Does the documentation support the patient has type I or II Diabetes and/or a lower extremity wound related to Diabetes as required per NCD 20.29 for the use of HBO to treat Diabetic Ulcers?

 

 

 

Does the supporting documentation include the nutritional assessment, glucose control, vascular status, and debridement history?

 

 

 

Is there documentation of failed wound care prior to beginning HBO for the treatment of the diabetic wound as required by NCD 20.29?

 

 

 

Does the documentation provided support a history of radiation exposure?

 

 

 

Does the documentation support HBO was used in combination with conventional treatment as required in NCD 20.29?

 

 

 

NCD — Hyperbaric Oxygen Therapy (20.29)

Disclaimer: This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS’s documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.


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