Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.06-012 - Ambulatory Surgical Center Update No. 64; Hospital Update No. 91 and Physician/Independent Lab/CRNA/Radiation Therapy Center Update No. 109

Current through Register Vol. 49, No. 6, June, 2024
Section II
Hospital/Critical Access Hospital (CAH)/End Stage Renal
			 Disease (ESRD)
217.130
Hyperbaric Oxygen Therapy 6-1-06
Hyperbaric Oxygen Therapy (HBO) involves exposing the body to
				oxygen under pressure greater than one atmosphere. Such therapy is performed in
				specially constructed hyperbaric chambers holding one or more patients,
				although, oxygen may be administered in addition to the hyperbaric treatment
				itself. Patients should be assessed for contraindications such as sinus disease
				or claustrophobia prior to therapy. In some diagnoses, hyperbarics is only an
				adjunct to standard surgical therapy. These indications are taken from "The
				Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and
				Hyperbaric Medical Society (Kensington, MD).
All hyperbaric therapy will require prior approval, except in
				emergency cases such as for air embolism or carbon monoxide poisoning. Prior
				approval will be for a certain number of treatments. A copy of the approval
				letter must be filed with each claim and the number in the series of treatments
				documented. Further treatments will require reapplication for a prior approval.
				Documentation for prior approval should include, but not be limited to, a
				complete physician SOAP note, a physical exam and prior therapy treatment
				failures, including antibiotic therapies and surgical interventions. It must
				include a clear description of the wound with each claim. Documentation of no
				measurable signs of healing for at least 30 consecutive days of wound care
				therapy prior to the start of HBO therapy should be included (for those
				diagnoses requiring this treatment plan). If an extension of benefits is
				needed, the above documentation must be submitted. Physician progress notes
				with physical findings at each treatment and the effects of treatment and wound
				description will be needed for an extension. Any questions may be addressed to
				the Medical Director at 501-682-9868.
Requests for prior approval may be mailed or faxed.
Mailing address:
Fax to:
ATTN: Medical Director
501-682-8013 or
Division of Medical Services
501-683-4124
P. O. Box 1437, Slot S412
ATTN: Medical Director
Little Rock, AR 72203-1437
The following tables provide explanation of diagnosis
				requirements and treatment number and treatment schedules.
Diagnosis
Description
Number of Treatments
6396, 67300, 9580, 9991
Air or Gas Embolism
10
9930
Decompression Sickness
10
986
Carbon Monoxide Poisoning
5
0400, 0383
Clostridial Myositis and Myonecrosis (Gas
						  Gangrene)
10
8690-8691, 8871, 8873, 8875, 8877, 8971, 8973, 8975,
						  8977, 9251-9299, 99690-99699
Crush injuries, compartment syndrome, other acute
						  traumatic peripheral ischemias
See Table
25070-25073, 44023, 44024, 44381-4439, 4540, 4542,
						  70700-7079, 9895, 99859
Enhancement of healing in selected problem wounds;
						  diabetic foot ulcers, pressure ulcers, venous stasis ulcers; only in severe and
						  limb or life-threatening wounds that have not responded to other treatments,
						  particularly if ischemia that cannot be corrected by vascular procedures is
						  present
30
3240
Intracranial abscess, multiple abscesses, immune
						  compromise, unresponsive
20
72886, 7854
Necrotizing Soft Tissue Infections, immune
						  compromise
30
73000-73020
Refractory osteomyelitis after aggressive surgical
						  debredement
40
52689, 73010-73019, 7854, 9092, 990
Delayed Radiation Injury
60
99652, 99660-99670, V423
Compromised skin grafts and flaps
20
9400-9495
Thermal burns[GREATER THAN]20% TSBA +/or involvement of
						  hands, face, feet or perineum that are deep, partial or full thickness
						  injury
40
Hyperbaric Treatment Schedules ("Doses") of
						  HBO2
ICD9 Code
Injury Type
Number & Schedule of
HBO2
Treatments
Number of HBO2 Treatments
						  Before Peer Review (Days)
Comments
9251-929.9
Crush Injuries according to Gustilo
						  classification
TIDª 2 days BID''2 days Daily for 2 days
6
9585
Compartment syndrome, impending stage fasciotomy not
						  required
TIDª for 1 day
1
If post-fasciotomy, see problem wound
						  recommendations
9400-9495, 99652, 99666-99670, V423
Threatened flaps & grafts
Same as for crush injuries
6
92951-929.9
Problem wounds after primary management
BID for 7d; daily 7 days
14
Post-fasciotomy wounds,
complications and residual wounds after primary
						  management of crush injuries
73000-73020
Refractory osteomyelitis
Daily for 21 days
21 +
May require continuation of HBO2
						  through 60 treatments, but reassessment and second stage peer review
						  recommended after 40 treatments
ªThree times a day -Twice a day
Refer to section 272.404 of this manual for billing
				instructions.
272.404
Hyperbaric Oxygen Therapy Procedures 6-1-06
A.
Facilities may bill for only one
			 unit of service per day.
The facility's charge for each
			 service date must include all its hyperbaric oxygen therapy charges, regardless
			 of how many treatment sessions per day are administered.
B. Facilities may bill for laboratory, X-ray,
			 machine tests and outpatient surgery in addition to procedure code
			 99183.
C. Hospitals and ambulatory
			 surgical centers must file paper claims for procedure code 99183 because the
			 claims are reviewed for medical necessity.
D. Indicate which treatment session is being
			 billed (for example, "Treatment session # 4") and attach pertinent progress and
			 treatment notes.
Procedure Code
Description
99183
Hyperbaric oxygen pressurization, facility charge, one
						  per day, outpatient
Refer to section 217.130 of this manual for coverage policy,
				diagnosis requirements and treatment schedules.
Physician/Independent Lab/CRNA/Radiation
				Therapy Center
258.000
Hyperbaric Oxygen
			 Therapy
Physicians may be reimbursed for attendance and supervision of
				hyperbaric oxygen therapy.
Hyperbaric oxygen therapy involves exposing the body to oxygen
				under pressure greater than one atmosphere. Such therapy is performed in
				specially constructed hyperbaric chambers holding one or more patients;
				although oxygen may be administered in addition to the hyperbaric treatment.
				Patients should be assessed for contraindications such as sinus disease or
				claustrophobia prior to therapy. In some diagnoses, hyperbarics is only an
				adjunct to standard surgical therapy. These indications are taken from "The
				Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and
				Hyperbaric Medical Society (Kensington, MD).
A. All hyperbaric therapy will require prior
			 approval, except in emergency cases such as for air embolism or carbon monoxide
			 poisoning. Prior approval will be for a certain number of treatments. A copy of
			 the approval letter must be filed with each claim and the number in the series
			 of treatments documented.
B.
			 Further treatments will require reapplication for a prior approval.
			 Documentation for prior approval should include, but not be limited to, a
			 complete physician SOAP note, a physical exam and prior therapy treatment
			 failures, including antibiotic therapies and surgical interventions.
1. It must include a clear description of the
			 wound with each claim. Documentation of no measurable signs of healing for at
			 least 30 consecutive days of wound care therapy prior to the start of HBO
			 therapy should be included (for those diagnoses requiring this treatment
			 plan).
2. If an extension of
			 benefits is needed, the above documentation must be submitted and fully
			 documented. Physician progress notes physical findings at each treatment and
			 the effects of treatment wound description will be needed for an extension. Any
			 questions may be addressed to the Medical Director at 501-682-9868.
3. Requests for prior approval may be mailed
			 or faxed.
Mailing address:
Fax to
ATTN: Medical Director
501-682-8013 or
Division of Medical Services
501-683-4124
Slot S412
ATTN: Medical Director
Department of Health and Human Services
PO Box 1437
Little Rock, AR 72203-1437
C. The following tables provide explanation
			 of diagnosis requirements and treatment number of treatments and treatment
			 schedules.
Diagnosis
Description
Number of Treatments
6396, 67300, 9580,9991
Air or Gas Embolism
10
9930
Decompression Sickness
10
986
Carbon Monoxide Poisoning
5
0400, 0383
Clostridial Myositis and Myonecrosis (Gas
						  Gangrene)
10
8690-8691, 8871, 8873, 8875, 8877, 8971, 8973, 8975,
						  8977, 9251-9299, 99690-99699
Crush injuries, compartment syndrome, other acute
						  traumatic peripheral ischemias
See Table
25070-25073, 44023, 44024, 44381-4439, 4540, 4542,
						  70700-7079, 9895, 99859
Enhancement of healing in selected problem wounds;
						  diabetic foot ulcers, pressure ulcers, venous stasis ulcers; only in severe and
						  limb or life-threatening wounds that have not responded to other treatments,
						  particularly if ischemia that cannot be corrected by vascular procedures is
						  present
30
3240
Intracranial abscess, multiple abscesses, immune
						  compromise, unresponsive
20
72886, 7854
Necrotizing Soft Tissue Infections, immune
						  compromise
30
73000-73020
Refractory osteomyelitis after aggressive surgical
						  debredement
40
52689, 73010-73019, 7854, 9092, 990
Delayed Radiation Injury
60
99652, 99660-99670, V423
Compromised skin grafts and flaps
20
9400-9495
Thermal burns [GREATER THAN] 20% TSBA +/or involvement
						  of hands, face, feet or perineum that are deep, partial or full thickness
						  injury
40
Hyperbaric Treatment Schedules ("Doses") of
						  HBO2
ICD9 Code
Injury Type
Number & Schedule of
HBO2
Treatments
Number of HBO2 Treatments
						  Before Peer Review (Days)
Comments
9251-929.9
Crush Injuries according to Gustilo
						  classification
TIDa 2 days
						  BIDb 2 days Daily for 2 days
6
9585
Compartment syndrome,
impending stage
fasciotomy not required
TIDa for 1 day
1
If post-fasciotomy,
see
problem wound
						  recommendations
9400-9495, 99652, 99666-99670, V423
Threatened flaps & grafts
Same as for crush injuries
6
92951-929.9
Problem wounds after primary management
BIDb for 7d; daily 7
						  days
14
Post-fasciotomy wounds, complications and residual
						  wounds after primary management of crush injuries
73000-73020
Refractory osteomyelitis
Daily for 21 days
21 +
May require continuation of HBO2
						  through 60 treatments, but reassessment and second stage peer review
						  recommended after 40 treatments
aThree times a day 
				bTwice a day
Refer to section 292.860 of this manual for billing
				instructions.
292.860
Hyperbaric Oxygen Therapy Procedures 6-1-06
Physicians may be reimbursed for attendance and supervision of
				hyperbaric oxygen therapy. Physicians billing for the physician component of
				"Physician attendance and supervision of hyperbaric oxygen therapy"
may
				bill for only one unit of service per day.
The physician's
				charge for each service date must include all his or her hyperbaric oxygen
				therapy charges, regardless of how many treatment sessions per day are
				administered.
A.
			 Physicians may bill for surgery and professional components of anatomical lab
			 procedures, X-rays and machine tests in addition to
99183
.
B. Physicians
			 must file paper claims for
99183
because the claims are reviewed
			 for medical necessity.
1. Indicate which
			 treatment session is being billed (for example, "Treatment session # 4") and
			 attach pertinent progress and treatment notes.
2. Use type of service code "
1
"
			 (paper claims only).
Refer to section 258.000 of this manual for coverage policy,
				diagnosis requirements and treatment schedules.
Ambulatory Surgical
				Center
216.800
Hyperbaric Oxygen Therapy
			 6-1-06
Hyperbaric Oxygen Therapy (HBO) involves exposing the body to
				oxygen under pressure greater than one atmosphere. Such therapy is performed in
				specially constructed hyperbaric chambers holding one or more patients,
				although oxygen may be administered in addition to the hyperbaric treatment
				itself. Patients should be assessed for contraindications such as sinus disease
				or claustrophobia prior to therapy. In some diagnoses, hyperbarics is only an
				adjunct to standard surgical therapy. These indications are taken from "The
				Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and
				Hyperbaric Medical Society (Kensington, MD).
All hyperbaric therapy will require prior approval, except in
				emergency cases such as for air embolism or carbon monoxide poisoning. Prior
				approval will be for a certain number of treatments. A copy of the approval
				letter must be filed with each claim and the number in the series of treatments
				documented. Further treatments will require reapplication for a prior approval.
				Documentation for prior approval should include, but not be limited to, a
				complete physician SOAP note, a physical exam and prior therapy treatment
				failures, including antibiotic therapies and surgical interventions. It must
				include a clear description of the wound with each claim. Documentation of no
				measurable signs of healing for at least 30 consecutive days of wound care
				therapy prior to the start of HBO therapy should be included (for those
				diagnoses requiring this treatment plan). If an extension of benefits is
				needed, the above documentation must be submitted. Physician progress notes
				with physical findings at each treatment and the effects of treatment and wound
				description will be needed for an extension. Any questions may be addressed to
				the Medical Director at 501-682-9868.
Requests for prior approval may be mailed or faxed.
Mailing address:
Fax to:
ATTN: Medical Director
501-682-8013 or
Division of Medical Services
501-683-4124
P. O. Box 1437, Slot S412
ATTN: Medical Director
Little Rock, AR 72203-1437
The following tables provide explanation of diagnosis
				requirements and treatment number and treatment schedules.
Number of
Diagnosis
Description
Treatments
6396, 67300, 9580, 9991
Air or Gas Embolism
10
9930
Decompression Sickness
10
986
Carbon Monoxide Poisoning
5
0400, 0383
Clostridial Myositis and Myonecrosis (Gas
						  Gangrene)
10
8690-8691, 8871, 8873, 8875, 8877, 8971, 8973, 8975,
						  8977, 9251-9299, 99690-99699
Crush injuries, compartment syndrome, other acute
						  traumatic peripheral ischemias
See Table
25070-25073, 44023, 44024, 44381-4439, 4540, 4542,
						  70700-7079, 9895, 99859
Enhancement of healing in selected problem wounds;
						  diabetic foot ulcers, pressure ulcers, venous stasis ulcers; only in severe and
						  limb or life-threatening wounds that have not responded to other treatments,
						  particularly if ischemia that cannot be corrected by vascular procedures is
						  present
30
3240
Intracranial abscess, multiple abscesses, immune
						  compromise, unresponsive
20
72886, 7854
Necrotizing Soft Tissue Infections, immune
						  compromise
30
73000-73020
Refractory osteomyelitis after aggressive surgical
						  debredement
40
52689, 73010-73019, 7854, 9092, 990
Delayed Radiation Injury
60
99652, 99660-99670, V423
Compromised skin grafts and flaps
20
9400-9495
Thermal burns[GREATER THAN]20% TSBA +/or involvement of
						  hands, face, feet or perineum that are deep, partial or full thickness
						  injury
40
Hyperbaric Treatment Schedules ("Doses") of
						  HBO2
Number & Schedule of
HBO2
Number of HBO2 Treatments
						  Before Peer
ICD9 Code
Injury Type
Treatments
Review (Days)
Comments
9251-929.9
Crush Injuries according to Gustilo
						  classification
TIDª 2 days BID''2 days Daily for 2 days
6
9585
Compartment syndrome, impending stage fasciotomy not
						  required
TIDª for 1 day
1
If post-fasciotomy, see problem wound
						  recommendations
9400-9495, 99652, 99666-99670, V423
Threatened flaps & grafts
Same as for crush injuries
6
92951-929.9
Problem wounds after primary management
BID- for 7d; daily 7 days
14
Post-fasciotomy wounds,
complications and residual wounds after primary
						  management of crush injuries
Ambulatory Surgical
				Center
Hyperbaric Treatment Schedules ("Doses") of
						  HBO2
ICD9 Code
Injury Type
Number & Schedule of
HBO2
Treatments
Number of HBO2 Treatments
						  Before Peer Review (Days)
Comments
73000-73020
Refractory osteomyelitis
Daily for 21 days
21 +
May require continuation of HBO2
						  through 60 treatments, but reassessment and second stage peer review
						  recommended after 40 treatments
ªThree times a day ""Twice a day
Refer to section 242.145 of this manual for billing
				instructions.
242.145
Hyperbaric Oxygen Therapy Procedures 6-1-06
A.
Facilities may bill for only one
			 unit of service per day.
The facility's charge for each
			 service date must include all its hyperbaric oxygen therapy charges, regardless
			 of how many treatment sessions per day are administered.
B. Facilities may bill for laboratory, X-ray,
			 machine tests and outpatient surgery in addition to procedure code
			 99183.
C. Hospitals and ambulatory
			 surgical centers must file paper claims for procedure code 99183 because the
			 claims are reviewed for medical necessity.
D. Indicate which treatment session is being
			 billed (for example, "Treatment session # 4") and attach pertinent progress and
			 treatment notes.
Procedure Code
Description
99183
Hyperbaric oxygen pressurization, facility charge, one
						  per day, outpatient
Refer to section
				216.800 of this manual for
				coverage policy, diagnosis requirements and treatment
				schedules.