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Medicare Guidelines

HBO therapy remains a covered Medicare service and should be reported with procedure code 99183, Physician attendance and supervision of hyperbaric oxygen therapy, per session. The following guidelines regarding HBO therapy are taken from the CMS Internet On-Line Manual and continue to be in effect:
For purposes of coverage under Medicare, hyperbaric oxygen (HBO) therapy is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure.

After 30 Days of No Results with Standard Care, Discuss With Your Patient The Next Level of Treatment

The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient's vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.

Covered Conditions

Program reimbursement for HBO therapy will be limited to that which is administered in a chamber (including the one man unit) and is limited to the following conditions:
1. Acute carbon monoxide intoxication.
2. Decompression illness.
3. Gas embolism.
4. Gas gangrene.
5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened.
6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened.
7. Progressive necrotizing infections (necrotizing fasciitis).
8. Acute peripheral arterial insufficiency.
9. Preparation and preservation of compromised skin grafts (not for primary management of wounds).
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management.
11. Osteoradionecrosis as an adjunct to conventional treatment.
12. Soft tissue radionecrosis as an adjunct to conventional treatment.
13. Cyanide poisoning.
14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment.
15. Diabetic wounds of the lower extremities in patients who meet the following three criteria:

1. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
2. Patient has a wound classified as Wagner grade III or higher; and
3. Patient has failed an adequate course of standard wound therapy.
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1. Hyperbaric oxygen therapy for nonhealing vasculitic ulcers. (.pdf)
2. Hyperbaric oxygen therapy for chronic diabetic wounds of the lower limbs--a review of the literature. (.pdf)
3. Salvage of limb and function in necrotizing fasciitis of the hand: role of hyperbaric oxygen treatment and free muscle flap coverage. (.pdf)
4. Hyperbaric hyperoxia suppresses growth of Staphylococcus aureus , including methicillin-resistant strains.
5. Risk Factors For Surgical Site Infection
6. Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2,809 consecutive patients.
7. Risk factors for leg harvest surgical site infections after coronary artery bypass graft surgery.

Hyperbaric hyperoxia suppresses growth of Staphylococcus aureus, including methicillin-resistant strains

Isao Tsuneyoshi1, Walter A. Boyle III1, Yuichi Kanmura2 and Toushiro Fujimoto3
(1) Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Avenue, Box 8054, St. Louis, MO 63110, USA, US
(2) Department of Anesthesiology and Critical Care Medicine, Kagoshima University School of Medicine, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan, JP
(3) Department of Medicine, Fujimoto Hospital, 17-4 Hayasucho, Miyakonojo, Miyazaki 885-0055, Japan, JP
Abstract   Purpose. We investigated the effects of increased oxygen tension on the in vitro growth of Staphylococcus aureus (MRSA), methicillin-sensitive Staphylococcus aureus (MSSA), and Escherichia coli (E. coli).
Methods. The effects of oxygen tension [normobaric normoxia (21% O2 at 1 atm), normobaric hyperoxia (100% O2 at 1 atm), hyperbaric normoxia (21% O2 at 2 atm), and hyperbaric hyperoxia (100% O2 at 2 atm) on the in vitro growth of MRSA, MSSA, and E. coli were investigated by population analysis.
Results. Compared with normobaric normoxia, a 90-min exposure to hyperbaric hyperoxia significantly inhibited growth of both MRSA (by 25.0 ± 3.0%, mean ± SEM; P < 0.01) and MSSA (by 24.0 ± 3.3%; P < 0.01). Normobaric hyperoxia and hyperbaric normoxia were without effect. In contrast, the growth of E. coli was not affected by any of the above treatments.
Conclusion. Our results indicate that the bacterium S. aureus, including resistant strains, is susceptible to oxygen stress. The observation that relatively brief (90-min) treatment with hyperbaric hyperoxia is sufficient to produce significant growth inhibition suggests that hyperbaric hyperoxia may be useful in the treatment of serious staphylococcal infections.
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Risk factors for surgical site infection in spinal surgery.

Division of Infectious Diseases and Neurosurgery, Washington University School of Medicine, St Louis, Missouri 63110, USA. molsen@im.wustl.edu
OBJECT: The objective of this study was to identify specific independent risk factors for surgical site infections (SSIs) occurring after laminectomy or spinal fusion. METHODS: The authors performed a retrospective case-control study of data obtained in patients between 1996 and 1999 who had undergone laminectomy and/or spinal fusion. Forty-one patients with SSI or meningitis were identified, and data were compared with those acquired in 178 uninfected control patients. Risk factors for SSI were determined using univariate analyses and multivariate logistic regression. The spinal surgery-related SSI rate (incisional and organ space) during the 4-year study period was 2.8%. Independent risk factors for SSI identified by multivariate analysis were postoperative incontinence (odds ratio [OR] 8.2, 95% confidence interval [CI] 2.9-22.8), posterior approach (OR 8.2, 95% CI 2-33.5), procedure for tumor resection (OR 6.2, 95% CI 1.7-22.3), and morbid obesity (OR 5.2, 95% CI 1.9-14.2). In patients with SSI the postoperative hospital length of stay was significantly longer than that in uninfected patients (median 6 and 3 days, respectively; p < 0.001) and were readmitted to the hospital for a median additional 6 days for treatment of their infection. Repeated surgery due to the infection was required in the majority (73%) of infected patients. CONCLUSIONS: Postoperative incontinence, posterior approach, surgery for tumor resection, and morbid obesity were independent risk factors predictive of SSI following spinal surgery. Interventions to reduce the risk for these potentially devastating infections need to be developed.
PMID: 12650399 [PubMed - indexed for MEDLINE]
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Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2,809 consecutive patients.
Tang R, Chen HH, Wang YL, Changchien CR, Chen JS, Hsu KC, Chiang JM, Wang JY.
Colorectal Section, Chang Gung Memorial Hospital, Linkou, Taiwan.
OBJECTIVE: To identify the risk factors for surgical site infection (SSI) in patients undergoing elective resection of the colon and rectum. SUMMARY BACKGROUND DATA: SSI causes a substantial number of deaths and complications. Determining risk factors for SSI may provide information on reducing complications and improving outcome. METHODS: The authors performed a prospective study of 2,809 consecutive patients undergoing elective colorectal resection via laparotomy between February 1995 and December 1998 at a single institution. The outcome of interest was SSI, which was classified as being incisional or organ/space with or without clinical leakage. A likelihood ratio forward regression model was used to assess the independent association of variables with SSIs. RESULTS: The overall SSI, incisional SSI, and organ/space SSI with and without clinical anastomotic leakage rates were 4.7%, 3%, 2%, and 0.8%, respectively. Risk factors for overall SSI were American Society of Anesthesiology (ASA) score 2 or 3 (odd ratio [OR] = 1.7), male gender (OR = 1.5), surgeons (OR = 1.3-3.3), types of operation (OR = 0.3-2.1), creation of ostomy (OR = 2.1), contaminated wound (OR = 2.9), use of drainage (OR = 1.6), and intra- or postoperative blood transfusion (1-3 units, OR = 5.3; >/=4 units, OR = 6.2). However, SSIs at specific sites differed from each other with respect to the risk factors. Among a variety of risk factors, only blood transfusion was consistently associated with a risk of SSI at any specific site. CONCLUSIONS: In addition to ASA score and surgical wound class, blood transfusion, creation of ostomy, types of operation, use of drainage, sex, and surgeons were important in predicting SSIs after elective colorectal resection.
PMID: 11505063 [PubMed - indexed for MEDLINE]
PMCID: PMC1422004
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Risk factors for leg harvest surgical site infections after coronary artery bypass graft surgery.
Olsen MA, Sundt TM, Lawton JS, Damiano RJ Jr, Hopkins-Broyles D, Lock-Buckley P, Fraser VJ.
Washington University School of Medicine, Division of Infectious Diseases, 660 South Euclid Ave, Campus Box 8051, St Louis, MO 63110-1093, USA. molsen@im.wustl.edu
OBJECTIVE: Harvest site infections are more common than chest surgical infections after coronary artery bypass surgery, yet few studies detail risk factors for these infections. We sought to determine independent risk factors for leg surgical site infections using our institutional Society of Thoracic Surgeons database. METHODS: We retrospectively analyzed data collected from 1980 coronary artery bypass patients undergoing surgery at our institution from January 1, 1996, through June 30, 1999, using The Society of Thoracic Surgeons database. Independent risk factors for leg harvest site infection were identified by multivariate logistic regression. RESULTS: Seventy-six patients (4.5%) were coded as having had a leg harvest site infection, of which 67 were confirmed by infection control. The length of hospital stay after surgery was significantly longer in patients with leg harvest site infection (mean 10.1 days) compared with that of patients without infection (mean 7.1 days, P <.001), and infected patients were more likely to be readmitted to the hospital within 30 days of surgery. Independent risk factors for leg harvest site infection included previous cerebrovascular accident (odds ratio, 2.9), postoperative transfusion of 5 units or more of red blood cells (odds ratio, 2.8), obesity (odds ratio, 2.5), age 75 years or older (odds ratio, 1.9), and female gender (odds ratio, 1.8). CONCLUSIONS: Consistent with previous studies, female gender and obesity were identified as independent risk factors for leg harvest site infection, while previous cerebrovascular accident, postoperative transfusion, and older age are newly described risk factors. The Society of Thoracic Surgeons database is a useful tool for identification of predictors of leg harvest site infections.
PMID: 14566237 [PubMed - indexed for MEDLINE]
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