Pre-Payment Review Results for Hyperbaric Oxygen Therapy for Q3 2025
Pre-Payment Review Results for Hyperbaric Oxygen (HBO) Therapy for Targeted Probe and Educate (TPE) for July through September 2025
The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for Healthcare Common Procedure Coding System (HCPCS) code G0277 for HBO Therapy. The reviews with edit effectiveness are presented here for North Carolina, South Carolina, Virginia and West Virginia.
Cumulative Results
|
Number of Providers with Edit Effectiveness |
Providers Compliant Completed/Removed After Probe |
Providers Non-Compliant Progressing to Subsequent Probe |
Providers Non-Compliant/Removed for Other Reason |
|---|---|---|---|
| 7 | 4 | 3 | 0 |
|
Number of Claims with Edit Effectiveness |
Number of Claims Denied |
Overall Claim Denial Rate |
Total Dollars Reviewed |
Total Dollars Denied |
Overall Charge Denial Rate |
|---|---|---|---|---|---|
|
169 |
85 |
50% |
$174,215.38 |
$43,741.14 |
25% |
Probe Two Findings
|
State |
Number of Providers with Edit Effectiveness |
Providers Compliant Completed/Removed After Probe |
Providers Non-Compliant Progressing to Subsequent Probe |
Providers Non-Compliant/Removed for Other Reason |
|---|---|---|---|---|
| N.C. | 2 | 1 | 1 | 0 |
| S.C. | 1 | 1 | 0 | 0 |
| Va. | 3 | 2 | 1 | 0 |
| W.Va. | 1 | 0 | 1 | 0 |
|
State |
Number of Claims with Edit Effectiveness |
Number of Claims Denied |
Overall Claim Denial Rate |
Total Dollars Reviewed |
Total Dollars Denied |
Overall Charge Denial Rate |
|---|---|---|---|---|---|---|
| N.C. | 49 | 25 | 51% | $20,863.93 | $11,746.77 | 56% |
| S.C. | 20 | 0 | 0% | $8,739.90 | $0 | 0% |
| Va. | 60 | 21 | 35% | $127,159.41 | $15,669.61 | 12% |
| W.Va. | 40 | 39 | 98% | $17,452.14 | $16,324.76 | 94% |
Risk Category
The risk categories for HCPCS code G0277 for HBO Therapy are defined as:
| Risk Category | Error Rate |
|---|---|
| Minor | 0–20% |
| Major | 21–100% |
Figure 1. Risk Category for HBO Therapy HCPCS Code G0277.
Top Denial Reasons
|
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
|---|---|---|---|
| 44% | 5D164, 5H164 | No Documentation of Medical Necessity | 4 |
| 44% | 5D920, 5H920 | The Recommended Protocol Was Not Ordered and/or Followed | 4 |
| 11% | 5D151, 5H151 | Units Billed More Than Ordered | 1 |
Denial Reasons and Recommendations
5D164/5H164 — No Documentation of Medical Necessity
Reason for Denial
This claim was denied because the documentation submitted does not support the medical necessity of the service reviewed. The records did not contain any covered condition/indication, symptomology or diagnostic results that would support the service was reasonable and necessary for the treatment of the beneficiary.
How to Avoid This Denial
- Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:
- A covered indication or condition for the service billed
- A physician/nonphysician provider (NPP) is managing the care of the covered indication or condition
- Any medical history that supports a need for the service
- Any diagnostic results or symptomology that supports a need for the service
- Legible documentation
- Submit all documentation to support ongoing skills of a qualified therapist were required to complete the treatment and that the initiation of therapy treatment services were medically necessary
- Advance Beneficiary Notice of Non-Coverage (ABN) is valid, complete and submitted in the record if applicable
- A legible physician or NPP signature is required on all documentation necessary to support medical necessity
- Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis
- Submit treatment note documentation that contains date of treatment, description of modality/procedure to support accurate billing, total treatment minutes/total timed code treatment minutes and signature of qualified professional
- Documentation to include the therapy discharge note and summary
- All documentation submitted is legible
References
- 42 Code of Federal Regulations (CFR), Sections 409.44(c)(2) and 410.60(c)(2)
- Social Security Act (SSA), Section 1862(a)(1)(A)
- LCDs, NCDs, Coverage Articles
- CMS Internet-Only Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220.2, 220.2A, 220.2B, 230.1C and 230.2C (PDF)
- CMS IOM, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Sections 3.3.2.4, 3.4.1.3, 3.6.2.1 and 3.6.2.2 (PDF)
- Medicare Learning Network (MLN)® Fact Sheet MLN905364, Complying with Medicare Signature Requirements (PDF)
5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed
Reason for Denial
Medicare cannot pay for this service because one or more requirements for coverage were not met.
How to Avoid This Denial
Documentation that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:
For Drugs and Biologicals:
- Clear physician’s order with indication of need, dose, frequency, administration time and route
- Date and time of associated chemotherapy, as applicable
- Relevant medical history documented prior to the date of service (DOS) and signed by the physician or appropriate NPP to include, but not limited to:
- Clear indication of the diagnosis and need for the related service(s)
- Clinical signs and symptoms
- Prior treatment and response as applicable
- Stage of treatment as applicable
- Documentation of administration and signed by the person providing the service
- Ensure the service was provided per the coverage guidelines for the service
For Outpatient Therapy:
- Clear physician’s order with indication of specific skilled service, frequency and duration
- Relevant medical history documented prior to the DOS and signed by the physician or appropriate NPP to include, but not limited to:
- Clear indication of the diagnosis and need for the related therapy services
- Documentation related to the therapy services to include beneficiary's functional level, treatment plan, short-and long-term goals, beneficiary's response to therapy services, treatment and progress notes
- Prior treatment and response as applicable
- Ensure the service was provided per the coverage guidelines for the service
For Intensity Modulated Radiation Therapy (IMRT):
- Clear physician/radiation oncologist orders for radiation treatment course, including specific anatomical target volumes, treatment technique, current dosage, type of radiation measuring and monitoring devices to be used and treatment fields
- Relevant medical history documented prior to the DOS and signed by the physician/radiation oncologist or appropriate NPP to include:
- Clear indication of the diagnosis being treated and medical necessity of the services
- Supporting reports such as dosimetry, physicist, simulation, oncology and radiology
- Documentation of design and construction of multi-leaf collimator
- Detailed itemized bill and supporting documentation of all billed services
- Documentation of treatment plan, including goals, treatment notes, specific dose constraints for the target and administration
- Ensure the service was provided per the coverage guidelines for the service
References
- LCDs, NCDs, Coverage Articles
- Drugs and Biologicals and Outpatient Therapy: CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 50, 220 and 230 (PDF)
- Drugs and Biologicals: CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17 (PDF)
- IMRT: CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, Section 200.3.1 (PDF)
5D151/5H151 — Units Billed More Than Ordered
Reason for Denial
The medical record provided for the outpatient service did not support the number of units billed on the claim. Per the documentation, more units were billed than provided.
How to Avoid This Denial
Under the Outpatient Prospective Payment System (OPPS), when HCPCS code reporting is required, the number of times the service or procedure was performed or the amount of the service used must also be accurately reported in the service units.
- For time-based general outpatient services, make sure the start and end time or total length of the service is documented clearly in the record
- For other general outpatient services, make sure the amount of the service is documented clearly in the record
- When reporting drugs or biologicals, make sure the amount of the drug given is clearly documented and properly converted into units when submitted for payment
- For outpatient therapy services, make sure the timed treatment minutes/unit(s) for the timed services provided are documented clearly in the record
References
- 42 CFR, Sections 410.27 and 424.5
- General Outpatient Billing: CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.4 (PDF)
- Drugs and Biologicals: CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, Section 90.2 (PDF)
- Outpatient Therapy Services: CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.2.C (PDF)
Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of educational methods are offered such as webinar sessions, web-based presentations and teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form (PDF).
Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the one-on-one post-probe education call date.