Hyperbaric Oxygen Reason Code Crosswalk

Published 05/04/2020

Palmetto GBA is currently updating systems to incorporate the standardized CMS reason codes and statements. In the interim, please see below list of Palmetto GBA denial codes and the corresponding CMS reason codes and statements. For more information related to CMS reason codes, please refer to the CMS website.

HBO — Denial Reason Crosswalk

Palmetto GBA Full Denial Code Palmetto GBA Partial Denial Code Palmetto GBA Granular Denial Reason Palmetto Denial Description CMS Reason Code CMS Statement
5D169 5H169 The medical records submitted do not match the beneficiary billed on the Hyperbaric Oxygen (HBO) therapy claim (HBO6E). Services Not Documented. HBO6E The medical records submitted do not match the beneficiary billed on the Hyperbaric Oxygen (HBO) therapy claim.
5D169 5H169 Date(s) of service on the documentation do not match the date(s) of service billed on the claim for Hyperbaric Oxygen Therapy, (HBO6A). Services Not Documented. HBO6A Date(s) of service on the documentation do not match the date(s) of service billed on the claim for Hyperbaric Oxygen Therapy.
5D164 5H164 Documentation does not include history and physical along with any previous treatment (i.e. antibiotic therapy, surgical interventions) for specified condition, (HBO1A). Doc submitted does not support med nec (provider liable). HBO1A Documentation does not include history and physical along with any previous treatment (i.e. antibiotic therapy, surgical interventions) for specified condition.
5D164 5H164 Progress updates with response to treatment and measurable signs of healing not provided, (HBO1F). Doc submitted does not support med nec (provider liable). HBO1F Progress updates with response to treatment and measurable signs of healing not provided.                 
5D164 5H164 The documentation does not include a covered diagnosis per the NCD, (HBO1B). Doc submitted does not support med nec (provider liable). HBO1B The documentation does not include a covered diagnosis per the NCD.
5D920 5H920 There is no documentation that patient has chronic refractory osteomyelitis, (HBO2L). The recommended protocol was not ordered and/or followed. HBO2L There is no documentation that patient has chronic refractory osteomyelitis.
5D920 5H920 Documentation of diagnostic test and/or labs not provided to support specified condition, (HBO1I). The recommended protocol was not ordered and/or followed. HBO1I Documentation of diagnostic test and/or labs not provided to support specified condition. 
5D920 5H920 There is no documentation indicating patient was unresponsive to conventional medical and surgical management for chronic refractory osteomyelitis, (HBO2M). The recommended protocol was not ordered and/or followed. HBO2M There is no documentation indicating patient was unresponsive to conventional medical and surgical management for chronic refractory osteomyelitis. 
5D920 5H920 There is no documentation patient has both type I or type II diabetes and a lower extremity wound that is due to diabetes, (HBO2U). The recommended protocol was not ordered and/or followed. HBO2U There is no documentation patient has both type I or type II diabetes and a lower extremity wound that is due to diabetes.
5D920 5H920 There is no documentation patient has failed an adequate course of standard wound therapy for diabetic wound management, (HBO2W). The recommended protocol was not ordered and/or followed. HBO2W There is no documentation patient has failed an adequate course of standard wound therapy for diabetic wound management.
5D920 5H920 There is no documentation patient has a diabetic wound classified as Wagner grade III or higher, (HBO2V). The recommended protocol was not ordered and/or followed. HBO2V There is no documentation patient has a diabetic wound classified as Wagner grade III or higher.
5D920 5H920 There is no documentation addressing the patient's nutritional status for diabetic wound management, (HBO2Y). The recommended protocol was not ordered and/or followed. HBO2Y There is no documentation addressing the patient's nutritional status for diabetic wound management.
5D920 5H920 There is no documentation indicating the patient's vascular status was addressed for diabetic wound management, (HB2AB). The recommended protocol was not ordered and/or followed. HB2AB There is no documentation indicating the patient's vascular status was addressed for diabetic wound management.
5D920 5H920 There is no documentation indicating optimal glucose control for diabetic wound management, (HB2AC). The recommended protocol was not ordered and/or followed. HB2AC There is no documentation indicating optimal glucose control for diabetic wound management.
5D920 5H920 There is no documentation indicating that the appropriate off-loading measures have been utilized for diabetic wound management, (HB2AD). The recommended protocol was not ordered and/or followed. HB2AD There is no documentation indicating that the appropriate off-loading measures have been utilized for diabetic wound management.
5D920 5H920 There is no documentation showing measurable signs of improvement of the diabetic wound after 30 days of Hyperbaric Oxygen (HBO) therapy, (HB2AG). The recommended protocol was not ordered and/or followed. HB2AG There is no documentation showing measurable signs of improvement of the diabetic wound after 30 days of Hyperbaric Oxygen (HBO) therapy.
5D920 5H920 HBO2N: There is no documentation that patient has Osteoradionecrosis, (HBO2N). The recommended protocol was not ordered and/or followed. HBO2V There is no documentation patient has a diabetic wound classified as Wagner grade III or higher.
5D920 5H920 There is no documentation that treatment is an adjunct to conventional treatment for osteoradionecrosis, (HBO2O). The recommended protocol was not ordered and/or followed. HBO2Y There is no documentation addressing the patient's nutritional status for diabetic wound management.
5D920 5H920 There is no documentation that patient has soft tissue Radionecrosis, (HBO2P). The recommended protocol was not ordered and/or followed. HB2AB There is no documentation indicating the patient's vascular status was addressed for diabetic wound management.
5D920 5H920 There is no documentation that treatment is an adjunct to conventional treatment for soft tissue Radionecrosis, (HBO2Q). The recommended protocol was not ordered and/or followed. HB2AC There is no documentation indicating optimal glucose control for diabetic wound management.
5D920 5H920 There is no documentation that patient needs preparation and/or preservation of compromised skin grafts, (HBO2K). The recommended protocol was not ordered and/or followed. HB2AD There is no documentation indicating that the appropriate off-loading measures have been utilized for diabetic wound management.
5D920 5H920 There is no documentation that patient has acute traumatic peripheral ischemia, (HBO2E). The recommended protocol was not ordered and/or followed. HB2AG There is no documentation showing measurable signs of improvement of the diabetic wound after 30 days of Hyperbaric Oxygen (HBO) therapy.
5D920 5H920 There is no documentation that adjunctive treatment was used in combination with accepted standard therapeutic measures when loss of function, limb or life is threatened for acute traumatic peripheral ischemia, (HBO2F). The recommended protocol was not ordered and/or followed. HBO2F There is no documentation that adjunctive treatment was used in combination with accepted standard therapeutic measures when loss of function, limb or life is threatened for acute traumatic peripheral ischemia.
5D920 5H920 There is no documentation of crush injuries and suturing of severed limbs, (HBO2G). The recommended protocol was not ordered and/or followed. HBO2G There is no documentation of crush injuries and suturing of severed limbs.
5D920 5H920 There is no documentation of adjunctive treatment when loss of function, limb, or life is threatened for crush injuries and suturing of severed limbs, (HBO2H). The recommended protocol was not ordered and/or followed. HBO2H There is no documentation of adjunctive treatment when loss of function, limb, or life is threatened for crush injuries and suturing of severed limbs.
5D920 5H920 There is no documentation that patient has acute peripheral arterial insufficiency, (HBO2J). The recommended protocol was not ordered and/or followed. HBO2J There is no documentation that patient has acute peripheral arterial insufficiency.
5D920 5H920 No documentation to support that patient has acute peripheral arterial insufficiency, (HBO2J). The recommended protocol was not ordered and/or followed. HBO2J There is no documentation that patient has acute peripheral arterial insufficiency.
5D920 5H920 There is no documentation that treatment is an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment for Actinomycosis, (HBO2T). The recommended protocol was not ordered and/or followed. HBO2T There is no documentation that treatment is an adjunct to conventional therapy
when the disease process is refractory to antibiotics and surgical treatment for
actinomycosis.
5D169 5H169 Hyperbaric Oxygen (HBO) therapy treatment records not provided or did not include the ascent time, descent time, total compression time, dose of oxygen, pressurization level, documentation of attendance, and a recording of events, (HBO1C). Services Not Documented. HBO1C Hyperbaric Oxygen (HBO) therapy treatment records not provided or did not include the ascent time, descent time, total compression time, dose of oxygen, pressurization level, documentation of attendance, and a recording of events.
5D169 5H169 Documentation does not indicate the entire body was exposed to oxygen under increased atmospheric pressure, (HBO1G). Services Not Documented. HBO1G Documentation does not indicate the entire body was exposed to oxygen under increased atmospheric pressure.
5D151 5H151 Number of units billed does not match treatment log, (HBO6G). Units Billed More Than Ordered. HBO6G Number of units billed does not match treatment log.
5D199 5H199 All or part of the claim was billed in error by the provider. Billing Error. GAK09 Documentation does not support the claim as billed. Refer to Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 100-04 Medicare Claims Processing Manual, Chapter 23.
5DMDP 5HMDP Dependent, qualifying services medically denied Dependent, qualifying srvc medically denied. GAJ02 Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15.
5DTDP 5HTDP Dependent, qualifying services technically denied. Dependent, qualifying srvc technically denied GAJ02 Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15.