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CMS Transmittals



National Coverage Determination
Procedure Code: 8XXXX
Hyperbaric Oxygen Therapy
CMS Policy Number: 20.29
Back to NCD List



To review all requirements of this policy, please see: CMS NCD listing by Chapter

Covered ICD-10 Codes.

ICD-10Descriptor
A42.0 Pulmonary actinomycosis
A42.1 Abdominal actinomycosis
A42.2 Cervicofacial actinomycosis
A42.89 Other forms of actinomycosis
A42.9 Actinomycosis, unspecified
A43.0 Pulmonary nocardiosis
A43.1 Cutaneous nocardiosis
A43.8 Other forms of nocardiosis
A43.9 Nocardiosis, unspecified
A48.0 Gas gangrene
B47.1 Actinomycetoma
B47.9 Mycetoma, unspecified
I74.2 Embolism and thrombosis of arteries of the upper extremities
I74.3 Embolism and thrombosis of arteries of the lower extremities
I74.5 Embolism and thrombosis of iliac artery
L08.1 Erythrasma
L59.8 Oth disrd of the skin, subcu related to radiation
M27.2 Inflammatory conditions of jaws
M27.8 Other specified diseases of jaws
M72.6 Necrotizing fasciitis
M86.311 Chronic multifocal osteomyelitis, right shoulder
M86.312 Chronic multifocal osteomyelitis, left shoulder
M86.321 Chronic multifocal osteomyelitis, right humerus
M86.322 Chronic multifocal osteomyelitis, left humerus
M86.331 Chronic multifocal osteomyelitis, right radius and ulna
M86.332 Chronic multifocal osteomyelitis, left radius and ulna
M86.341 Chronic multifocal osteomyelitis, right hand
M86.342 Chronic multifocal osteomyelitis, left hand
M86.351 Chronic multifocal osteomyelitis, right femur
M86.352 Chronic multifocal osteomyelitis, left femur
M86.361 Chronic multifocal osteomyelitis, right tibia and fibula
M86.362 Chronic multifocal osteomyelitis, left tibia and fibula
M86.371 Chronic multifocal osteomyelitis, right ankle and foot
M86.372 Chronic multifocal osteomyelitis, left ankle and foot
M86.38 Chronic multifocal osteomyelitis, other site
M86.39 Chronic multifocal osteomyelitis, multiple sites
M86.411 Chronic osteomyelitis with draining sinus, right shoulder
M86.412 Chronic osteomyelitis with draining sinus, left shoulder
M86.421 Chronic osteomyelitis with draining sinus, right humerus
M86.422 Chronic osteomyelitis with draining sinus, left humerus
M86.431 Chronic osteomyelit w draining sinus, right radius and ulna
M86.432 Chronic osteomyelitis w draining sinus, left radius and ulna
M86.441 Chronic osteomyelitis with draining sinus, right hand
M86.442 Chronic osteomyelitis with draining sinus, left hand
M86.451 Chronic osteomyelitis with draining sinus, right femur
M86.452 Chronic osteomyelitis with draining sinus, left femur
M86.461 Chronic osteomyelit w draining sinus, right tibia and fibula
M86.462 Chronic osteomyelit w draining sinus, left tibia and fibula
M86.471 Chronic osteomyelitis w draining sinus, right ankle and foot
M86.472 Chronic osteomyelitis w draining sinus, left ankle and foot
M86.48 Chronic osteomyelitis with draining sinus, other site
M86.49 Chronic osteomyelitis with draining sinus, multiple sites
M86.511 Other chronic hematogenous osteomyelitis, right shoulder
M86.512 Other chronic hematogenous osteomyelitis, left shoulder
M86.521 Other chronic hematogenous osteomyelitis, right humerus
M86.522 Other chronic hematogenous osteomyelitis, left humerus
M86.531 Oth chronic hematogenous osteomyelit, right radius and ulna
M86.532 Oth chronic hematogenous osteomyelitis, left radius and ulna
M86.541 Other chronic hematogenous osteomyelitis, right hand
M86.542 Other chronic hematogenous osteomyelitis, left hand
M86.551 Other chronic hematogenous osteomyelitis, right femur
M86.552 Other chronic hematogenous osteomyelitis, left femur
M86.561 Oth chronic hematogenous osteomyelit, right tibia and fibula
M86.562 Oth chronic hematogenous osteomyelit, left tibia and fibula
M86.571 Oth chronic hematogenous osteomyelitis, right ankle and foot
M86.572 Oth chronic hematogenous osteomyelitis, left ankle and foot
M86.58 Other chronic hematogenous osteomyelitis, other site
M86.59 Other chronic hematogenous osteomyelitis, multiple sites
M86.611 Other chronic osteomyelitis, right shoulder
M86.612 Other chronic osteomyelitis, left shoulder
M86.621 Other chronic osteomyelitis, right humerus
M86.622 Other chronic osteomyelitis, left humerus
M86.631 Other chronic osteomyelitis, right radius and ulna
M86.632 Other chronic osteomyelitis, left radius and ulna
M86.641 Other chronic osteomyelitis, right hand
M86.642 Other chronic osteomyelitis, left hand
M86.651 Other chronic osteomyelitis, right thigh
M86.652 Other chronic osteomyelitis, left thigh
M86.661 Other chronic osteomyelitis, right tibia and fibula
M86.662 Other chronic osteomyelitis, left tibia and fibula
M86.671 Other chronic osteomyelitis, right ankle and foot
M86.672 Other chronic osteomyelitis, left ankle and foot
M86.68 Other chronic osteomyelitis, other site
M86.69 Other chronic osteomyelitis, multiple sites
M86.8X0 Other osteomyelitis, multiple sites
M86.8X1 Other osteomyelitis, shoulder
M86.8X2 Other osteomyelitis, upper arm
M86.8X3 Other osteomyelitis, forearm
M86.8X4 Other osteomyelitis, hand
M86.8X5 Other osteomyelitis, thigh
M86.8X6 Other osteomyelitis, lower leg
M86.8X7 Other osteomyelitis, ankle and foot
M86.8X8 Other osteomyelitis, other site
N30.40 Irradiation cystitis without hematuria
N30.41 Irradiation cystitis with hematuria
S35.511A Injury of right iliac artery, initial encounter
S35.512A Injury of left iliac artery, initial encounter
S45.011A Laceration of axillary artery, right side, initial encounter
S45.012A Laceration of axillary artery, left side, initial encounter
S45.091A Oth injury of axillary artery, right side, init encntr
S45.092A Oth injury of axillary artery, left side, init encntr
S45.111A Laceration of brachial artery, right side, initial encounter
S45.112A Laceration of brachial artery, left side, initial encounter
S45.191A Oth injury of brachial artery, right side, init encntr
S45.192A Oth injury of brachial artery, left side, init encntr
S45.211A Laceration of axillary or brachial vein, right side, init
S45.212A Laceration of axillary or brachial vein, left side, init
S45.291A Inj axillary or brachial vein, right side, init encntr
S45.292A Inj axillary or brachial vein, left side, init encntr
S47.1XXA Crushing injury of right shoulder and upper arm, init encntr
S47.2XXA Crushing injury of left shoulder and upper arm, init encntr
S57.01XA Crushing injury of right elbow, initial encounter
S57.02XA Crushing injury of left elbow, initial encounter
S57.81XA Crushing injury of right forearm, initial encounter
S57.82XA Crushing injury of left forearm, initial encounter
S67.01XA Crushing injury of right thumb, initial encounter
S67.02XA Crushing injury of left thumb, initial encounter
S67.190A Crushing injury of right index finger, initial encounter
S67.191A Crushing injury of left index finger, initial encounter
S67.192A Crushing injury of right middle finger, initial encounter
S67.193A Crushing injury of left middle finger, initial encounter
S67.194A Crushing injury of right ring finger, initial encounter
S67.195A Crushing injury of left ring finger, initial encounter
S67.196A Crushing injury of right little finger, initial encounter
S67.197A Crushing injury of left little finger, initial encounter
S67.21XA Crushing injury of right hand, initial encounter
S67.22XA Crushing injury of left hand, initial encounter
S67.31XA Crushing injury of right wrist, initial encounter
S67.32XA Crushing injury of left wrist, initial encounter
S67.41XA Crushing injury of right wrist and hand, initial encounter
S67.42XA Crushing injury of left wrist and hand, initial encounter
S75.011A Minor laceration of femoral artery, right leg, init encntr
S75.012A Minor laceration of femoral artery, left leg, init encntr
S75.021A Major laceration of femoral artery, right leg, init encntr
S75.022A Major laceration of femoral artery, left leg, init encntr
S75.091A Oth injury of femoral artery, right leg, init encntr
S75.092A Oth injury of femoral artery, left leg, init encntr
S77.01XA Crushing injury of right hip, initial encounter
S77.02XA Crushing injury of left hip, initial encounter
S77.11XA Crushing injury of right thigh, initial encounter
S77.12XA Crushing injury of left thigh, initial encounter
S77.21XA Crushing injury of right hip with thigh, initial encounter
S77.22XA Crushing injury of left hip with thigh, initial encounter
S85.011A Laceration of popliteal artery, right leg, initial encounter
S85.012A Laceration of popliteal artery, left leg, initial encounter
S85.091A Oth injury of popliteal artery, right leg, init encntr
S85.092A Oth injury of popliteal artery, left leg, init encntr
S87.01XA Crushing injury of right knee, initial encounter
S87.02XA Crushing injury of left knee, initial encounter
S87.81XA Crushing injury of right lower leg, initial encounter
S87.82XA Crushing injury of left lower leg, initial encounter
S97.01XA Crushing injury of right ankle, initial encounter
S97.02XA Crushing injury of left ankle, initial encounter
S97.111A Crushing injury of right great toe, initial encounter
S97.112A Crushing injury of left great toe, initial encounter
S97.121A Crushing injury of right lesser toe(s), initial encounter
S97.122A Crushing injury of left lesser toe(s), initial encounter
S97.81XA Crushing injury of right foot, initial encounter
S97.82XA Crushing injury of left foot, initial encounter
T57.3X1A Toxic effect of hydrogen cyanide, accidental, init
T57.3X2A Toxic effect of hydrogen cyanide, self-harm, init
T57.3X3A Toxic effect of hydrogen cyanide, assault, initial encounter
T57.3X4A Toxic effect of hydrogen cyanide, undetermined, init encntr
T58.01XA Toxic effect of carb monx from mtr veh exhaust, acc, init
T58.02XA Toxic eff of carb monx from mtr veh exhaust, slf-hrm, init
T58.03XA Toxic effect of carb monx from mtr veh exhaust, asslt, init
T58.04XA Toxic effect of carb monx from mtr veh exhaust, undet, init
T58.11XA Toxic effect of carb monx from utility gas, acc, init
T58.12XA Toxic effect of carb monx from utility gas, self-harm, init
T58.13XA Toxic effect of carb monx from utility gas, assault, init
T58.14XA Toxic effect of carb monx from utility gas, undet, init
T58.2X1A Tox eff of carb monx fr incmpl combst dmst fuel, acc, init
T58.2X2A Tox eff of carb monx fr incmpl combst dmst fuel,slf-hrm,init
T58.2X3A Tox eff of carb monx fr incmpl combst dmst fuel, asslt, init
T58.2X4A Tox eff of carb monx fr incmpl combst dmst fuel, undet, init
T58.8X1A Toxic effect of carb monx from oth source, accidental, init
T58.8X2A Toxic effect of carb monx from oth source, self-harm, init
T58.8X3A Toxic effect of carb monx from oth source, assault, init
T58.8X4A Toxic effect of carb monx from oth source, undet, init
T58.91XA Toxic effect of carb monx from unsp source, acc, init
T58.92XA Toxic effect of carb monx from unsp source, self-harm, init
T58.93XA Toxic effect of carb monx from unsp source, assault, init
T58.94XA Toxic effect of carb monx from unsp source, undet, init
T65.0X1A Toxic effect of cyanides, accidental (unintentional), init
T65.0X2A Toxic effect of cyanides, intentional self-harm, init encntr
T65.0X3A Toxic effect of cyanides, assault, initial encounter
T65.0X4A Toxic effect of cyanides, undetermined, initial encounter
T70.29XA Other effects of high altitude, initial encounter
T70.3XXA Caisson disease [decompression sickness], initial encounter
T79.0XXA Air embolism (traumatic), initial encounter
T80.0XXA Air embolism fol infusion, tranfs and theraputc inject, init
T86.820 Skin graft (allograft) rejection
T86.821 Skin graft (allograft) (autograft) failure
T86.822 Skin graft (allograft) (autograft) infection
T86.828 Other complications of skin graft (allograft) (autograft)
T87.0X1 Complications of reattached (part of) right upper extremity
T87.0X2 Complications of reattached (part of) left upper extremity
T87.1X1 Complications of reattached (part of) right lower extremity
T87.1X2 Complications of reattached (part of) left lower extremity
T87.2 Complications of other reattached body part

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All code-pairs and Medicare coverage information are compiled directly from Center for Medicare and Medicaid Services (CMS) and Medicare Contractor coverage policies. CodeMap® has made every reasonable effort to ensure the accuracy of the information contained. However, the ultimate responsibility for correct coding and claims submission lies with the provider of services. Both CMS and Medicare contractor coverage policy information may change at any time. CodeMap® makes no representation, warranty, or guarantee that this compilation of coverage policy information is error-free or that the use of this information will result in Medicare coverage and subsequent payment of claims. Final coverage and payment of claims are subject to many factors exclusively controlled by CMS and its contractors.


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