Hyperbaric Oxygen Therapy G0277 Physician Responsibilities and Required Documentation

Published 02/28/2025

Hyperbaric Oxygen (HBO) Therapy is a medical treatment that involves breathing pure oxygen within a pressurized chamber. The pressure in the chamber is typically higher than the atmospheric pressure, which allows more oxygen to be dissolved in the blood. 

Some Benefits of HBO Therapy

  • Increases oxygen levels in the blood which can promote healing and reduce inflammation
  • Assists in destroying bacteria and other harmful organisms
  • Contributes to the improvement of blood flow to damaged tissues

Some of the covered diagnoses for HBO therapy have specific requirements that must be met per NCD 20.29 before they can be covered.

  • Compromised skin grafts
  • Chronic refractory osteomyelitis
  • Actinomycosis
  • Diabetic wounds
  • Acute traumatic peripheral ischemia, crush injuries, sutured severed limbs
  • Osteoradionecrosis, soft tissue radionecrosis
  • Acute peripheral arterial insufficiency 

Per CMS requirements, the patient’s primary care physician or specialist must provide direct supervision of HBO outpatient services and be readily available to provide immediate physical presence for assistance and direction throughout the procedure.

Additionally, the primary care physician must periodically see the patient to:

  • Assess the course of treatment
  • Monitor patient progress
  • Make any necessary changes to the treatment regimen

An HBO Treatment plan must include the following:

  • Number of treatments
  • Length of each individual treatment
  • Progress updates; including the patient’s response to therapy

Documentation for HBO-Covered Diagnoses 

Compromised Skin Graft

  • Mottling/random pattern of ischemia
  • Suture line dehiscence
  • Areas of eschar
  • Partial loss of flap
  • Threatened loss of complete flap

Compromised Split/Full Thickness Skin Graft

  • Failure of adherence
  • Partial loss of skin graft
  • Complete loss of skin graft

Preparation of Previously Failed Skin Graft Site

  • Present site matches previous anatomical failure site
  • Granulation tissue to support new graft placement
  • Tissue oxygenation adequate to support new graft

Note: If an infection is present be sure to treat prior to HBO therapy and continue to document all measures taken to treat any infection.

Chronic Refractory Osteomyelitis Documentation
Previous failed conventional treatments include:

  • Antibiotics (oral or intravenous), for a minimum of four weeks with no improvement prior to HBO initiation
  • Debridement with dates of procedure or reason why not performed 
  • Previous local wound care regimen
  • Means to offload

Chronic Refractory Osteomyelitis Wound Care Documentation 

  • Maintenance of a clean, moist wound bed
  • Use of appropriate moist dressings
  • Offloading as appropriate to the anatomical area
  • Any diagnostic studies to confirm the diagnosis (X-ray, bone biopsy, three-phase bone scan, CT, MRI)

Actinomycosis
Documentation must indicate that the condition has been resistant to antibiotics and surgical intervention. Only then can HBOT be approved as adjunct therapy.

Diabetic Wounds
Must meet three criteria to qualify for the diagnosis

  1. Type I or type II diabetes and with a lower extremity wound that is due to diabetes
  2. Wound classified as Wagner Grade III or higher 
  3. Patient has failed an adequate course of standard wound therapy (no measurable signs of healing for 30 days with standard wound care)

If HBO is appropriate, the wound must be:

  • Reevaluated and documented at least every 30 days for measurable signs of healing during the use of HBO therapy
  • There must be documented measurable signs of healing with each 30-day evaluation of the wound for the continued therapy 

What are measurable signs of healing?

  • Decrease in wound size
  • Decrease in amount of exudate
  • Decrease in amount of necrotic tissue
  • Improvement in tissue perfusion
  • New epithelial tissue growth or granulation

Acute Traumatic Peripheral Ischemia, Crush Injuries, Sutured Severed Limbs
Used as an adjunctive treatment in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. Document all standard treatments:

  • Medications to control pain, dilate blood vessels, prevent ongoing clot formation, and to reduce the heart’s workload
  • Procedures to expand blood vessels
  • Surgery or procedures to remove clots
  • Surgery to bypass blocked blood vessels
  • Thrombolytic drugs to dissolve clots

Osteoradionecrosis, Soft Tissue Radionecrosis
Documentation should clearly state that there is a history of radiation treatment/exposure, treatments prior to HBO and include: 

  • Pain and pain control (narcotic/non-narcotic)
  • Surgical intervention (debridement, skin graft, skin flap)
  • Local wound care
  • Telangiectasia (dilation of capillaries that cause small red/purple clusters on the skin)
  • Ulceration
  • Tissue necrosis or breakdown

Gynecologic Radionecrosis
Documentation must include:

  • Signs and symptoms
    • Dryness
    • Bleeding
    • Pain
    • Stenosis
    • Dyspareunia
    • Telangiectasia (vascular lesion caused by dilated blood vessels)
    • Ulceration
    • Necrosis
    • Atrophy

Previous Management

  • Pain control
  • Hormone replacement for dryness
  • Bleeding (include if the beneficiary received transfusions, iron therapy, surgery)
  • Surgical intervention or dilation for stenosis
  • Surgical repair, surgical graft and/or debridement for ulceration/necrosis

Acute Peripheral Arterial Insufficiency 
Used in combination with surgery on a post operative basis (secondary treatment), documentation must include: 

  • Origin of the condition
  • Reconstruction/graft thrombosis
  • Iatrogenic trauma (caused by medical examination/treatment)
  • Native thrombosis
  • Embolism
  • Peripheral aneurysm with embolism or thrombus

Include any diagnostic testing

  • Arteriogram
  • CT angiogram
  • MR angiogram

Previous treatment(s)

  • Anticoagulation
  • Pharmacologic thrombosis
  • Percutaneous aspiration/mechanical thromboembolectomy

Mandibular Osteoradionecrosis

Stage 1: Minimal exposed bone with no major manifestations of symptoms (no debridement or minor debridement).

Stage 2: Patient who do not progress with stage 1 (To be stage 2 surgery must maintain mandibular continuity).

Stage 3: Mandibular continuity cannot be achieved during surgical debridement (must undergo mandibular resection followed by planned reconstruction).

Documentation must include:

  • Signs and symptoms
    • Exposed aveolar bone 
    • Mandibular fracture
    • Trismus 
    • Necrosis
    • Orocutaneous fistulae
       
  • Previous Management
    • Pain control (surgical intervention, narcotic, non-narcotic)
    • Superficial debridement
    • Oral saline irrigation
    • Transoral sequestrectomy (removal of bone that has separated from the mandible)
    • Orocutaneous fistula repair
    • Mandibular resection

Note: You cannot bill HBO for preventive or prophylactic therapy.

Other Supporting Documentation

Other documentation that may support Medicare claims for any/all diagnoses related to utilization of HBO therapy may include:

  • The signed and dated order for therapy to be administered and the number of units to be received
  • Progress notes
  • Physician/NPP orders
  • Medication Administration Records
  • History and Physical (H&P) 
  • Laboratory and diagnostic testing confirming the diagnosis 
  • Any other pertinent clinical documentation that may support medical necessity
  • Third party medical record documentation related to HBO therapy
  • Nutritional assessments (prior to HBO) including:
    • Albumin
    • Pre-albumin
    • Total protein
    • Measures taken to correct any deficiencies
  • Glucose levels and control (prior to HBO)
    • Serial blood glucose
    • Hgb A1C
    • Measure taken to control blood glucose

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