Understanding Osteopathic Manipulative Treatment and E/M Billing Risks
auditing, e/m billing, e/m coding, e/m audits, CMS, cpt, e/m services, ebrief, icd-10, CPT codes, Billing, icd-10-cm, OMT, OMM, T.A.R.T.
Understanding Osteopathic Manipulative Treatment (OMT)
Is it appropriate to bill an evaluation and management service when osteopathic manipulative treatment (OMT) is performed at the same visit? We must address a few fundamental principles to answer this question adequately. Having spent ten years managing a medical practice specializing in osteopathic manipulative medicine (OMM), I learned quickly that this specialty could often be an enigma even to seasoned medical coders and auditors. I found that OMT, a treatment utilized by physicians specializing in OMM, can not only be misunderstood by the patient population but widely misunderstood by many payors. It is crucial to foundationally understand OMT to properly code and bill for these services.
Osteopathy is a branch of medicine emphasizing the interrelated unity of all systems in the body, working synchronously to heal in times of illness. Doctors of Osteopathic Medicine (DO’s) believe that the state of good health goes beyond the absence of disease or pain. The philosophy of osteopathic medicine is to recognize the whole body as an integrated being rather than independently operating body systems. They employ a unique, whole-body approach to create optimal health in every medical specialty, from pediatrics to neurology.
One of the common treatment techniques utilized by DO’s is OMT. OMT is a set of manual, hands-on techniques to diagnose, treat, and prevent illness or injury. OMT can treat structural and functional issues in the body’s bones, joints, tissues, and muscles. Additionally, OMT uses the interconnected relationship between the neuromusculoskeletal system and other body systems to promote whole-body healing.
There are many different forms of OMT. A few examples are listed below:
- Active Method
- Counter Strain
- Functional Method
- Indirect Method
- Myofascial Release
- Cranial Manipulation
- Percussion Vibrator Technique
- Visceral Manipulation
OMT is a medication-free, non-invasive treatment option. It is used to treat a wide variety of ailments such as migraines, arthritis, fibromyalgia, carpal tunnel syndrome, rotator cuff problems, and stress and sports injuries, to name a few. Aside from structural related issues, OMT is also an excellent treatment option for chronic sinusitis, vertigo, acid reflux, anxiety, depression, post-concussion syndrome, and the list goes on and on. Because most forms of OMT are so gentle, it is suitable for patients of all ages, from newborns to adults. OMT is excellent for newborns and infants to treat recurrent ear infections, colic, reflux, asthma, and other respiratory problems. While OMT is a manual treatment, there is often an energetic component to the treatment, meaning an energetic connection between the patient and physician when OMT is performed.
E/M Service, Diagnosis, and ICD-10 Codes
Patients generally do not present to a DO solely to receive OMT. An E/M service is necessary to address the presenting problem, followed by an examination performed by the osteopathic physician. The patient is examined to determine a diagnosis. A structural diagnosis involves observation and palpatory exam of the neuro-musculoskeletal system with its venous, lymphatic, and pulmonary interactions. However, examinations performed by osteopathic physicians are not limited to specific body systems. The goal is to identify impediments in health, including but not limited to somatic dysfunction. Somatic dysfunction is the impaired or altered function of related components of the body framework (somatic system). ICD-10 code(s) should be applied corresponding to the identified areas of somatic dysfunction. The ICD-10 codes are based on body regions:
- M99.00 – Segmental and somatic dysfunction of head region
- M99.01 – Segmental and somatic dysfunction of cervical region
- M99.02 – Segmental and somatic dysfunction of thoracic region
- M99.03 – Segmental and somatic dysfunction of lumbar region
- M99.04 – Segmental and somatic dysfunction of sacral region
- M99.05 – Segmental and somatic dysfunction of pelvic region
- M99.06 – Segmental and somatic dysfunction of lower extremity region
- M99.07 – Segmental and somatic dysfunction of upper extremity region
- M99.08 – Segmental and somatic dysfunction of rib region
- M99.09 – Segmental and somatic dysfunction of abdomen and other region
The diagnosis of somatic dysfunction is made by identifying the presence of one or more findings of Tenderness, Asymmetry, Restriction of Motion, and/or Tissue Abnormality, commonly known as T.A.R.T. Somatic dysfunction in one region can create compensatory somatic dysfunction in another body region. OMT is used to treat somatic dysfunction by normalizing musculoskeletal activity, thereby normalizing outflows through the sympathetic and parasympathetic nervous systems to visceral systems resulting in more normal visceral or other organ system function.
Unique Billing Requirements for OMT
Typically, a treatment plan is not created for OMT and this is one of the distinctive components separating it from other types of manual treatments. This distinction is important when establishing the necessity of billing a separate and identifiable E/M service with OMT. At each visit, the osteopathic physician determines whether OMT is an appropriate course of treatment for the presenting problem and may utilize different forms of OMT on different body regions. Other treatment modalities may also accompany OMT. It is not uncommon for osteopathic physicians to prescribe exercises, teach breathing techniques, refer to other specialties, perform medication management, or even perform trigger point injections.
It has long been the position of the American Osteopathic Association (AOA’s) that an osteopathic physician should report an evaluation and management service appended with modifier 25 with OMT on both initial and follow-up visits provided that the services are medically necessary and supported by the clinical documentation. The American Medical Association has affirmed the AOA’s position and the American Academy of Osteopathy that an evaluation and management service should be billed at the same visit as OMT. The CPT introductory language of the OMT codes specifies that modifier 25 indicates that a separate and identifiable E/M service was provided above the usual pre and post-service work. An amendment to the CPT introductory language was added in 1999, clarifying that a separate diagnosis is not required to report both an E/M and OMT on the same date of service. In 2002, the practice expense associated with the 5 OMT CPT codes (98925-9829) was reviewed by the RUC Advisory Committee. The committee recommended that the practice expense includes only the work of the OMT procedure itself. To translate, there is no evaluation and management component included in OMT. These recommendations were adopted by CMS in 2003 and hold true today.
Payors from CMS to United Healthcare have well-established coverage policies on OMT, while some private payors still have a gross misunderstanding of this treatment. I have worked with many private payors who inappropriately apply covered OMT services to physical therapy or chiropractic benefits upon claims processing. The American Osteopathic Association’s Physician Services Team engages with private payors to advocate on behalf of physicians to decrease administrative burden, streamline payment of claims, and improve patient outcomes. The AOA’s physician services team works directly with private payors when coverage policies delay payment or impede patient care.
Payors like United Healthcare have published coverage policies that indicate a broader understanding of this treatment.
The policy published by United Healthcare specifically states:
Note: Osteopathic Manipulative Treatment specifically encompasses only the procedure itself. Evaluation and management (E&M) services are covered as a separate and distinct service when medically necessary and appropriately documented.
CMS LCD Article A56954 also states that OMT utilized at a follow-up visit is not the same as follow-up OMT. A follow-up visit for OMT is a predetermined service and does not support a separate and identifiable E/M service. A follow-up visit where OMT is utilized is not necessarily predetermined unless the preceding chart note denotes the visit to be an OMT visit. In their coverage guidelines for OMT, Article A52435, Medicare Administrative Contractor, CGS states that an E/M service is not warranted for planned follow-up OMT treatments unless a new condition occurs or the patient’s condition has changed. This is also stated in United Healthcare’s OMT coverage guideline.
Medical Necessity Requirements
To adequately support the medical necessity of OMT as well as the E/M service, the documentation requirements, regardless of payor, all essentially state the same requirements must be met for:
- The medical record should support the medical necessity of the evaluation and management service and the osteopathic manipulative treatment.
- Documentation of examination findings of somatic dysfunction should describe pathology in the areas of skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements.
- One or more elements of TART should be documented in each region of somatic dysfunction treated with OMT.
- The selection of regions to which OMT is applied should reflect the regions of documented somatic dysfunction.
- The type of OMT used on a region should be clearly documented.
- Functional improvement or decline should be documented using objective measures. This is especially important when addressing chronic conditions.
- The clinically appropriate history and exam of the patient should identify any new conditions, if present or if the patient’s established condition(s) have changed substantially, necessitating an overall assessment.
Ensure Your Documentation is Compliant With Payor Coverage Guidelines
While implementing the above documentation requirements does not guarantee that payors will accurately process claims billed with both an evaluation and management service when provided with OMT, it does ensure that your documentation complies with well-established payor coverage guidelines and the recommendation of the associations known to be the leading authorities in osteopathic medicine.
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