Checklist: Hyperbaric oxygen (HBO) therapy documentation

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Home ► Med doc checklists ► Checklist: Hyperbaric oxygen (HBO) therapy documentation

Last Modified: 5/5/2023 Location: FL, PR, USVI Business: Part A, Part B

Checklist: Hyperbaric oxygen (HBO) therapy documentation

This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for hyperbaric oxygen therapy (HBO) services. Health care providers retain responsibility to submit complete and accurate documentation.

Check	Documentation description
	Documentation is for the correct beneficiary.
	Documentation is for the correct date(s) of service
	Documentation contains a valid and legible signature, which follows CMS Signature Guidelines for Medical Review Purposes .
	Documentation supporting the diagnosis established, treatment plan/goals and timeline by the referring or treating physician prior to the initiation of HBO therapy.
	Documentation of an initial assessment, which includes a history and physical examination that substantiates the condition for which HBO is recommended (including any prior medical, surgical and/or HBO treatments).
	Documentation of the procedure (logs) including ascent time, descent time and pressurization level.
	Documentation supporting the re-evaluation and effectiveness of treatment at least every 30 days (including wound evaluation) for response to therapy.
	Documentation to support physician-to-physician communications or records of consultations and/or additional assessments, recommendations or procedural reports.
	Documentation to support any laboratory or radiology findings in support of HBO treatments.
	Documentation of date and anatomical site of prior radiation treatments and/or date of the skin graft and compromised state of graft site (if applicable based on treatment diagnosis).
	Documentation to support the patient’s condition and response to treatment warrant the number of services reported.
	Documentation to support an available trained emergency response team and ICU services during the treatment(s).
	Documentation includes an advanced beneficiary notice of non-coverage was provided (if applicable and required)
	Any additional documentation to support medical necessity or any applicable policy guidelines for the services billed.

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 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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