Denied claims due to unauthorized patient procedures or services can be responsible for a major loss in revenue. Although most medical offices and provider-based departments are moving closer to 100% verification for patient services, there is still no guarantee that every account will be paid.
Claims that are denied due to no prior authorization happen primarily in a hospital setting. To ensure your claims will be paid, plan ahead, meticulously document, and follow the regulations as noted below.
Process
The coding of HBOT is represented by 2 separate CPT codes: 99183 and G0277. HCPCS defines CPT code 99183 as Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session. 99183 represents the professional component of the hyperbaric treatment and can only be billed as 1 unit.
The word supervision must be emphasized here. According to Federal Register 42 CFR, Direct supervision means that the physician or non-physician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure.
The physician is not required to be present in the room where the procedure is performed or within any other physical boundary as long as he or she is immediately available.
HCPCS defines CPT code G0277 as hyperbaric oxygen therapy, full body chamber, per 30 minutes. G0277 represents the facility component of the hyperbaric treatment. It is important to understand the 30-minute increment language and how it relates to prior authorization of HBOT.
The following example will illustrate this: the hyperbaric provider has consulted on the patient and determined that a course of 30 treatments will be needed for Soft Tissue Radionecrosis. The nurse or technologist clarifies the ICD-10 diagnoses with the HBO physician and gathers the clinical data to present to the carrier for prior authorization of services.
The following steps are important and necessary to ensure that both the physician and facility are paid for services.
- Verify coverage and benefits with the insurance carrier. Ask: "Does the patient have active coverage, is this insurance the primary and when does the plan expire?"
- Verify that the patient’s plan provides coverage for HBOT. It is important to provide them with the CPT codes, 99183 and G0277.
- Ask if codes 99183 and G0277 require prior authorization. If authorization is required, provide the number of units you will need for each CPT code
- If you are requesting 30 HBO treatments, the authorization request for 99183 would be 30 units.
- If you are requesting 30 HBO treatments, the authorization request for G0277 would be for the number of 30-minute increments multiplied by the number of requested treatments which in this case would be 120 units. 1 hyperbaric treatment is typically billed as four 30-minute increments.
- See table below for G0277 billing increments.
- Ask the representative to refer to their coverage determination on HBOT and ask if they cover the indication which in this case is STRN.
- Obtain a copy of the carrier’s coverage determination for HBOT prior to beginning therapy and highlight the indication and ICD-10 codes relevant to this authorization.
- Request a date span which will allow time for 30 HBO treatments to be administered. In this case, 60 days would be sufficient.
- Once authorization is given, document all of the above information clearly and thoroughly. This will include:
- The authorization number
- Number of treatments authorized
- Authorization start and end date
- Time, date and name of the person you spoke with
- A reference number that has been assigned to this phone call or case
- Request a faxed copy of the authorization
- Remind the patient that it is also their responsibility to make contact with their insurance company to ensure coverage, i.e., deductible, copay, coinsurance and maximum out-of-pocket expense.
- Communicate the HBO Authorization number and details to the billing department.
Closing
Recently, a hyperbaric facility received a denial notice on the explanation of benefits for hyperbaric treatments 11-40 specifically, the G0277 code. When the staff inquired as to why with UnitedHealthcare, they were informed that during the prior authorization process, they had requested authorization for 40 hyperbaric treatments. As of 10th hyperbaric treatments, UHC had already paid for 40 units of G0277 leaving the facility with a deficit of 120 units or 30 total treatments still to be paid. This would account for about $24,000 of lost revenue for one patient.
Resources
A HBOT prior authorization form template is provided here for reference (open access, after creating free account).
The WoundReference Hyberbaric Oxygen Therapy Knowledge Base features guidelines to promote high standards of patient care and operational safety within the hyperbaric program and other important tools. The WoundReference Curbside Consult gives you actionable, specific answers from our expert panel in a timely manner.
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