INTRODUCTION
Overview
This topic provides healthcare professionals a resource to identify and select ICD-10 codes for evidence-based indications accepted by the Undersea and Hyperbaric Medical Society (UHMS) and covered by Medicare [1], as well as indications that are accepted by the UHMS but are not covered by Medicare. A compilation of policies from commercial insurers regarding coverage of hyperbaric oxygen therapy (HBOT) is also included in this topic.
Background
The World Health Organization (WHO) maintains the International Classification of Diseases (ICD), a medical classification system used globally.[2]Use of the ICD codes in the United States (U.S.) is required for the classification of diseases and injuries under an agreement with the WHO. By using the ICD codes, the U.S. collects, processes, and presents mortality data in a similar way to other countries around the world. This permits comparison of data across countries. Periodically, new revisions are developed to reflect advances in medical science.
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The ICD is revised periodically and is currently in its 11th revision, which was released by the WHO for global use in 2022.[3][4] In the U.S., the 10th revision (ICD-10) is still active, with ICD-11 anticipated to be implemented in the coming years. However, the transition to ICD-11 in the U.S. will necessitate continuous and broadened efforts to accommodate the varied requirements of its users.[3][4]
ICD-10 Specific Hyperbaric Codes
In order to meet medical necessity, HBOT diagnoses fall into two groups: Single and Dual.
- Single Diagnosis codes mean that one ICD-10 codes from the accepted CMS list from National Coverage Determination (NCD) 20.29 will meet medical necessity for hyperbaric payment (for indications that fall under the single diagnosis rules, see section ‘xxx’ below)
- Dual Diagnosis codes mean that two ICD-10 codes from the accepted CMS list from National Coverage Determination (NCD) 20.29 will meet medical necessity for hyperbaric payment IF used in the appropriate order (for indications that fall under the dual diagnosis rules, see section ‘xxx’ below)
Hyperbaric Coding Examples
Single Diagnosis Code:
- Acute Carbon Monoxide Poisoning resulting from a residential faulty furnace
- T58.11XA-Toxic effect of carbon monoxide from utility gas, accidental (unintentional), initial encounter
- Chronic Refractory Osteomyelitis of the right foot
- M86.371 Chronic Multifocal Osteomyelitis right ankle and foot
- Osteoradionecrosis of the Mandible
- M27.2 Inflammatory conditions of the jaw
Dual Diagnosis Codes:
- Diabetic (type 2) Wagner 3 ulcer right heel with necrosis of muscle
- E11.621- Type 2 Diabetes Mellitus with foot ulcer
- L97.413 Non-pressure chronic ulcer of right heel and mid-foot with necrosis of muscle
- Soft Tissue Radiation Damage of the bladder with hematuria
- L59.8 Other disorder of the skin and subcutaneous tissue related to radiation (STRN)
- N30.41 Radiation Cystitis with hematuria (STRN)
EVIDENCED-BASED INDICATIONS ACCEPTED BY THE UHMS AND APPROVED BY MEDICARE
SINGLE DIAGNOSIS CODES
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One Code from this list will satisfy medical necessity (See group list below for dual diagnosis codes)
DUAL DIAGNOSIS CODES
Requires a code from group 1, followed by a code from group 2 for type of radiation
EVIDENCED-BASED INDICATIONS ACCEPTED BY THE UHMS BUT NOT APPROVED BY MEDICARE
COMMERCIAL COVERAGE DETERMINATIONS
Instructions
- To go to the commercial payer coverage determination policy, click on its reference number (in blue brackets). On the reference page, click on the green button “View Source” to go to the specific coverage determination for the Commercial Payer.
- See details on requirements, medical necessity and documentation on specific Coverage Determinations.
Commercial Payers
- Aetna [5]
- Humana [6]
- UHC [7]
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