Pressure Online

Nursing Notes


BRADLEY WALKER RN, CHT, UHMS Associate Nurse-Elect  •  E:

Challenges ahead

For those of us who have been in the wound care and hyperbaric medicine arena for many years, we are accustomed to seeing changes from the Centers for Medicare and Medicaid Services/CMS. However, what we have seen will not be as challenging as what we are facing now and in the future.

As hyperbaric clinical staff (nurses and technicians) our mission to is to support the physician while providing the best care for our patients. The physicians we support went to school to learn how to diagnose and treat patients. and trained to document the care provided and subsequent plan of care. They did not go to school to learn how to document tailored to reimbursement requirements and navigate the myriad regulations CMS, insurance contractors and other regulatory agencies imposed upon us. They have often had to learn the art of documentation on the job.

As health care professionals, our support as nurses and technicians means we must help fill in those gaps, becoming fluent and up to date on the latest standards, regulations, training and best practices. Although I will not go in depth into any of these categories during this article, I will highlight areas that you should become more knowledgeable about. Hopefully in our future columns we will address each category in more detail.

Know your LCD

First, it is important to become familiar with your LCD (local coverage determination) from your MAC, your Medicare Administrator Contractor. Several MACs may follow the National Coverage Determination/NCD for hyperbaric oxygen (HBO2). Also, look to see if your MAC has published any recent articles to further clarify its position on coverage, payment and documentation standards.  You should check monthly for any changes or updates. If you are with a wound care management company, it may have staff and resources helping you on this.

Know your QR measures

Next, CMS has imposed Quality Reporting/QR measures on physicians tied to reimbursement. You should determine which system they are on: (1) The Merit-based Incentive Payment System (MIPS); or (2) Advanced Alternative Payment Models (APMs). Determine which registry (i.e., US Wound Registry) the information is being reported to and what information is needed.

Know your preauthorization and prepayment standards

Third, CMS and the MACs have been using preauthorization for HBO2 in three states, and this has been a challenge. However, the real challenge is the use of prepayment review by the MACs. CMS has indicated the MACs can use this at will and many are starting to use it. What does this mean? In simple terms, it means that the facility and physician will provide their services, then submit to be paid.  If they do not meet the documentation requirements along with approved indications, they will not get paid. Thus, the service was provided without guarantee of payment.

Know your documentation

Finally, all of the above should indicate the need for improved documentation and the appropriate use of HBO2 in your clinical practices. Become the expert in what the current requirements are and ensure your electronic medical record adequately captures that information. Guide and support your physician in what the current requirements are. Provide whatever assistance you can to reduce the documentation burden on the physician while remembering there are certain areas that only the physician can document.

Know your job

Lastly, improve your knowledge and training by becoming a certified hyperbaric technician (CHT) or certified hyperbaric RN (CHRN). You may go to the National Board of Diving and Hyperbaric Medical Technology/NBDHMT ( or the ( to find more information on this.

Bradley Walker is Nurse Representative-Elect to the UHMS Board of Directors.