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Physician Supervision of Hyperbaric Oxygen Treatment

  In the October 2000 report of the Department of Health and Human Services Office of the Inspector General (OIG) on Hyperbaric Oxygen Therapy, Its Use and Appropriateness1 physician attendance at hyperbaric oxygen treatment sessions was discussed. Two perspectives on the meaning of attendance were identified during the review process:

     1. the physician is physically present during the entirety of the treatment and uses that time to manage the patient’s overall care; and
     2. physicians remain available to manage rare emergency situations but are not continually present or available.

  Of particular interest to the question of the value of physician attendance during hyperbaric oxygen treatment sessions was the conclusion drawn by the OIG in that same report.

   “Our review indicates physician attendance is strongly correlated with quality of care and the reduction of inappropriate billing. Almost two-thirds of medical directors do support the notion that physician attendance is necessary to achieve quality. Similarly, our medical review results supported this concept, showing a significant relationship (P <.001) between quality of care variables and physician attendance and between compliance with HCFA guidelines and physician attendance (P <.001). These relationships provide support for requiring physician attendance during all treatments. The strong relationship between quality and attendance suggests a potential for reducing inappropriate payments.” The implication of these observations is that direct physician involvement in the provision of hyperbaric oxygen treatment drives quality and cost effectiveness.

  AMA CPT 99183 states physician attendance and supervision of hyperbaric oxygen therapy, per session. Confusion has resulted from this description because of the ambiguity created by including two descriptions that could be considered to reflect very different performance requirements. For the remainder of this discussion, only requirements for physician billing for 99183 will be discussed.

  Hyperbaric oxygen treatment supervision by an unrestricted licensed physician. For a physician to bill 99183, the requirements for direct supervision must be met. According to federal regulations, direct supervision for purposes of hospital outpatient services means that "the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure." (42 C.F.R. § 410.27; CMS Transmittal B-01-28). For the physician, being in attendance during any key portion of each treatment session, seeing the patient before, during, or after the treatment, and being immediately available for any emergency or other assistance that is required during treatment should be sufficient for the physician to bill 99183. This interpretation is consistent with the relative value for this procedure assigned by CMS (then HCFA) in 1993 and allows the supervising hyperbaric medicine physician to treatment more than one patient at a time and to see wound care patients in the same or a contiguous area while supervising hyperbaric oxygen treatment. Although CMS (then HCFA) did make an attempt to define specific training and credentialing requirements for physicians supervising hyperbaric oxygen treatment in 1999, no specific requirements are in place at this time. It is the responsibility of each hospital medical staff to address minimum training, performance, and quality standards although professional organizations such as the Undersea and Hyperbaric Medical Society2 and the American College of Hyperbaric Medicine provide guidance in these areas.

  Hyperbaric oxygen treatment supervision by an advanced practice nurse. Nurse practitioners may perform services that would be physician services under Medicare. The statute only requires that such services must be within the scope of the practitioner’s state license (and potentially within the scope of local hospital privileges or credentials). The level of supervision required for such services is only a general level of supervision, ie, the procedure is furnished under the physicians overall direction and control, but the physician’s performance is not required during the performance of the procedure. All of the requirements for physician supervision of hyperbaric oxygen treatment listed above must be met by the nurse practitioner. In addition, a written collaborative agreement must be in place and documentation of that collaboration must be present in the medical record. It is this author’s recommendation that if hyperbaric oxygen treatment services are provided in a facility outside of the hospital (where immediate physician response in the event of an emergency is required), a qualified physician should remain in the facility where hyperbaric oxygen treatment is administered. Specific requirements relative to supervision and performance will vary by state and should be verified prior to permitting nurse practitioner supervision of hyperbaric oxygen treatment. The hospital medical staff should provide specific credentialing.

  Hyperbaric oxygen treatment supervision by a physician’s assistant. Physician assistants may perform services that would be physician services under Medicare. The statute only requires that such services must be within the scope of the practitioner’s state license (and potentially within the scope of local hospital privileges or credentials). The level of supervision required for such services is only a general level of supervision, ie, the procedure is furnished under the physicians overall direction and control, but the physician’s performance is not required during the performance of the procedure. The physician assistant must meet all of the requirements for physician supervision of hyperbaric oxygen treatment listed above. In addition, evidence of supervision by the sponsoring physician must be clearly evident within the medical record. It is this author’s recommendation that if hyperbaric oxygen treatment services are provided in a facility outside of the hospital (where immediate physician response in the event of an emergency is required), a qualified physician should remain in the facility where hyperbaric oxygen treatment is administered. Specific requirements relative to supervision and performance will vary by state and should be verified prior to permitting physician assistant supervision of hyperbaric oxygen treatment. The hospital medical staff should provide specific credentialing.

  Hyperbaric oxygen treatment supervision by a podiatrist. Podiatrist services are included as physician services under section 1861(r)(3) of the SSA but “only with respect to functions which he is legally authorized to perform as such by the state in her performs them.” In order for hyperbaric oxygen treatment services to be supervised by a podiatrist, the following requirements must be met. Hyperbaric oxygen treatment should be specifically designated by the state board of podiatric medicine/surgery as within the scope of podiatry practice and podiatry supervision of hyperbaric oxygen treatment limited to those conditions which clearly fall under the scope of podiatry practice (ie, treatment of a diabetic foot ulcer but not decompression sickness or osteoradionecrosis of the mandible). In addition, the local fiscal intermediary and carrier medical policies should be reviewed for other specific requirements or exceptions.

  Specific medical staff policies for credentialing podiatrists for supervision of hyperbaric oxygen treatment including minimum mandatory training, which should be equivalent to the training required for physicians and designation of the process for providing backup physician support in the event of a treatment complication (seizure, pneumothorax, etc.). All of the requirements outlined in the general requirements for physician supervision must be met. In addition, a designated, qualified physician should be immediately available to support the podiatrist in the event a complication of hyperbaric oxygen treatment occurs where management would fall outside of the scope of practice of the supervising podiatrist.

  A best practices recommendation for physician supervision of hyperbaric oxygen treatment that meets regulatory and reimbursement requirements and fosters optimal quality care should require each physician supervising hyperbaric oxygen treatment to:
     1. Be credentialed by the medical staff of the hospital operating the hyperbaric facility based upon adequate initial training and continuing education,
     2. Provide a complete consultation detailing the indication for hyperbaric oxygen treatment,
     3. Document any justification by primary or secondary diagnostic testing for such treatment,
     4. Provide an assessment of patient risk for treatment and a description of interventions planned to reduce such risk,
     5. Provide specific orders for treatment including treatment profile and number of treatments ordered, and
     6.Maintain periodic reassessment notes of the patient’s response to therapy justifying the need to continue or the ability to discontinue treatment. This periodic reassessment should occur at a minimum weekly and more often as indicated.

  In addition, the physician must be physically present within the facility whenever a patient(s) is receiving hyperbaric oxygen treatment. Robert A. Warriner, III, M.D., FACA, FCCP, FCCWS, ABPM/UHM, is the Emeritus Medical Director, Southeast Texas Center for Wound Care and Hyperbaric Medicine, Conroe Regional Medical Center, Conroe, Texas, Chief Medical Officer, Diversified Clinical Services, Jacksonville, Florida, Chairman, Federal and Regulatory Affairs Task Force, Undersea and Hyperbaric Medical Society.

References

1) Hyperbaric Oxygen Therapy, Its Use and Appropriateness, OEI 06-99-00090, Department of Healthy and Human Services Office of the Inspector General, October 2000, p12. 2) UHMS Guidelines for Hyperbaric Facility Operations, W.T. Workman (ed) Undersea and Hyperbaric Medical Society, Kensington, MD 2004 and the Clinical Hyperbaric Facility Accreditation Manual.

Robert A. Warriner, III, M.D., FACA, FCCP, FCCWS, ABPM/UHM
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