CMS Pub. 100-04, ch. 32, § 30.1

Lower Extremities

(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)

Hyperbaric Oxygen Therapy is a modality in which the entire body is exposed to oxygen under increased

atmospheric pressure. Effective April 1, 2003, a National Coverage Decision expanded the use of HBO therapy to

include coverage for the treatment of diabetic wounds of the lower extremities. For specific coverage criteria for

HBO Therapy, refer to the National Coverage Determinations Manual, Chapter 1, section 20.29.

NOTE: Topical application of oxygen does not meet the definition of HBO therapy as stated above. Also, its

clinical efficacy has not been established. Therefore, no Medicare reimbursement may be made for the topical

application of oxygen.

• Billing Requirements for A/B MACs (A)

Claims for HBO therapy should be submitted using the ASC X12 837 institutional claim format or, in rare cases,

on Form CMS-1450.

a. Applicable Bill Types

The applicable hospital bill types are 11X, 13X and 85X.

b. Procedural Coding

• 99183 – Physician attendance and supervision of hyperbaric oxygen therapy, per session.

• G0277 – Hyperbaric oxygen under pressure, full body chamber, per 30-minute interval.

NOTE: Code G0277 is not available for use other than in a hospital outpatient department. In skilled nursing

facilities (SNFs), HBO therapy is part of the SNF PPS payment for beneficiaries in covered Part A stays.

For hospital inpatients and critical access hospitals (CAHs) not electing Method I, HBO therapy is reported

under revenue code 940 without any HCPCS code. For inpatient services, if ICD-10 is applicable, show ICD-

10-PCS code 5A05121.

For CAHs electing Method I, HBO therapy is reported under revenue code 940 along with HCPCS code 99183.

c. Payment Requirements for A/B MACs (A)

Payment is as follows:

A/B MAC (A) payment is allowed for HBO therapy for diabetic wounds of the lower extremities when performed

as a physician service in a hospital outpatient setting and for inpatients. Payment is allowed for claims with valid

diagnosis codes as shown above with dates of service on or after April 1, 2003. Those claims with invalid codes

should be denied as not medically necessary.

For hospitals, payment will be based upon the Ambulatory Payment Classification (APC) or the inpatient

Diagnosis Related Group (DRG). Deductible and coinsurance apply.

Payment to Critical Access Hospitals (electing Method I) is made under cost reimbursement. For Critical Access

Hospitals electing Method II, the technical component is paid under cost reimbursement and the professional

component is paid under the Physician Fee Schedule.

II. A/B MAC (B) Billing Requirements

Claims for this service should be submitted using the ASC X12 837 professional claim format or Form CMS-

1500.

The following HCPCS code applies:

• 99183 – Physician attendance and supervision of hyperbaric oxygen therapy, per session.

• G0277 – Hyperbaric oxygen under pressure, full body chamber, per 30-minute interval.

a. Payment Requirements for A/B MACs (B)

Payment and pricing information will occur through updates to the Medicare Physician Fee Schedule Database

(MPFSDB). Pay for this service on the basis of the MPFSDB. Deductible and coinsurance apply. Claims from

physicians or other practitioners where assignment was not taken, are subject to the Medicare limiting charge.

III. Medicare Summary Notices (MSNs)

Use the following MSN Messages where appropriate:

In situations where the claim is being denied on the basis that the condition does not meet our coverage

requirements, use one of the following MSN Messages:

“Medicare does not pay for this item or service for this condition.” (MSN Message 16.48)

The Spanish version of the MSN message should read:

“Medicare no paga por este articulo o servicio para esta afeccion.”

In situations where, based on the above utilization policy, medical review of the claim results in a determination

that the service is not medically necessary, use the following MSN message:

“The information provided does not support the need for this service or item.” (MSN Message 15.4)

The Spanish version of the MSN message should read:

“La informacion proporcionada no confirma la necesidad para este servicio o articulo.”

IV. Remittance Advice Notices

Use appropriate existing remittance advice remark codes and claim adjustment reason codes at the line level to

express the specific reason if you deny payment for HBO therapy for the treatment of diabetic wounds of lower

extremities.

30.2 Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)

(Rev.3921, Issued: 11-17-17, Effective: 04-03-17, 12-18-17)

CMS considers topical oxygen therapy (TOT) to be a method whereby a local supply of oxygen is applied to a wound.

I. Billing Requirements for A/B MACs (A)

Claims for HBO therapy should be submitted using the ASC X12 837 institutional claim format or, in rare cases, on

Form CMS-1450.

II. Payment Requirements for A/B MACs (A)

As of April 3, 2017, Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by

the local contractors.

NOTE: Regardless of whether an A/B MAC (A) has made a determination to cover this service, there shall be no

coverage for any separate or additional physician’s professional services related to this procedure.

III. Billing Requirements for A/B MACs (B)

As of April 3, 2017, Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by

the local contractors.

NOTE: Regardless of whether an A/B MAC (B) has made a determination to cover this service, there shall be no

coverage for any separate or additional physician’s professional services related to this procedure.