Hyperbaric Oxygen Checklist

Published 09/26/2019

Providers can use this checklist as an audit tool to help assure that they are submitting all required documentation.  

 Hyperbaric Oxygen Checklist Yes No N/A
Is the documentation provided for the correct beneficiary?      
Is the documentation provided for the correct dates of service?      
Is there a valid order for services provided?      
Are the number and length of HBO treatments to be administered documented?      
Does the documentation provided support the medical necessity for HBOT?      
Does the medical record include measurable goals related to the treatment of the indication for HBO or HBO therapy?      
Does the medical record include progress updates that support the patient’s response to therapy and measurable signs of healing?      
Is the indicated diagnosis being treated with HBO covered by the NCD?      
Are there radiology, pathology, or lab reports to confirm the diagnosis of Chronic Refractory Osteomyelitis?      
Does the documentation support the patient has type I or II Diabetes and/or a lower extremity wound related to Diabetes as required per NCD 20.29 for the use of HBO to treat Diabetic Ulcers?      
Is there documentation of failed wound care prior to beginning HBO for the treatment of the diabetic wound as required by NCD 20.29?      
Does the documentation provided support a history of radiation exposure?      
Does the documentation support HBO was used in combination with conventional treatment as required in NCD 20.29?      

Disclaimer: This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS’s documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.