Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.09-038 - Hospital, Critical Access Hospital (CAH) and End-Stage Renal Disease (ESRD) Update # 161 & Physician / Independent Lab / CRNA / Radiation Therapy Center Update # 174

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 (HBOT)
Hyperbaric Oxygen Therapy (HBOT) 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).
HBOT prior authorizations will be issued by Arkansas Foundation
				for Medical Care (AFMC) for all requests received on and after October 1, 2009.
				All hyperbaric oxygen therapy will require prior authorization, except in
				emergency cases such as for air embolism or carbon monoxide poisoning, in which
				post-authorization will be allowed per protocol. See section 242.000. Prior
				authorization will be issued for a specific number of treatments. Subsequent
				treatments will require a telephone review and an additional prior
				authorization. All prior authorizations for HBOT are completed by telephone
				review.
In order to request a prior authorization for HBOT, the
				provider must call the AFMC prior authorization number, (800) 426-2234.
The caller must be able to provide demographic and clinical information to
				support the medical necessity of treatment. Calls for prior authorization
				should be placed by a staff member who can answer questions pertaining to the
				patient's clinical condition. Providers should gather all necessary information
				prior to placing a call. All information that is submitted to acquire the prior
				authorization must be documented in the beneficiary's medical record. The
				following information is required for prior authorization:
A. Name of caller requesting HBOT
B. Beneficiary's Medicaid ID number
C. Beneficiary's full name
D. Beneficiary's complete mailing address
			 including zip code
E. Beneficiary's
			 birth date
F. Treatment start
			 date
G. Treatment facility's AR
			 Medicaid provider number
H.
			 Treating physician's AR Medicaid provider number
I. Treating physician's office phone
			 number
J. CPT code for
			 treatment
K. ICD-9 diagnosis code
			 that justifies HBOT
L. Number of
			 treatments requested (see table below)
M. Clinical indications for treatment
1. Narrative diagnosis, history of illness
			 requiring HBOT and prior treatment including information about specific
			 treatments and length of time
2. If
			 treatment is for a non-healing wound, a clear description of the wound is
			 required
Refer to Section 242.000, 244.000, 252.119 and 272.404 for
				additional information on prior authorizations, reimbursement, and information
				on billing.
NOTE: When approved, only one authorization number will
				be issued. The prior authorization number and the number of approved HBOT
				treatments must be communicated to the physician provider so that both the
				facility and physician may claim reimbursement for the number of approved HBOT
				sessions. Additionally, if more HBOT sessions are required for the same
				beneficiary, a new prior authorization will be required and the above process
				followed to acquire any subsequent prior authorizations. A new prior
				authorization number will be assigned for any additional sessions approved. The
				prior authorization information between the facility and the physician is to be
				reciprocal if the physician acquires the prior authorization.
The following table provides the diagnosis requirements,
				description of the problem, and number of treatments.
Diagnosis
6396, 67300, 9580, 9991
Description
Air or Gas Embolism
Number of Treatments
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
6
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
						  debridement
40
52689, 73010-73019, 7854, 9092, 990
Delayed Radiation Injury
60
99660 - 99769, 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
40
thickness injury
95890 - 95899
Compartment syndrome, impending stage fasciotomy not
						  required.
1
9251 - 9299
Problem wounds after primary management
14
Refer to section 272.404 of this manual for billing
				instructions.