Reducing claim denials for osteopathic manipulative treatment (OMT) begins with a clear understanding of osteopathic medicine, appropriate coding practices, and payer-specific coverage requirements.
A common question is whether an evaluation and management (E/M) service may be reported on the same date as OMT. The answer depends on medical necessity, the services performed, and the supporting documentation. OMT can be complex from a coding and auditing perspective because it is sometimes misunderstood by patients, medical coders, auditors, and payers. Understanding the purpose and clinical foundations of OMT is therefore essential for accurate coding and billing.
Understanding Osteopathic Medicine
Osteopathic medicine emphasizes the relationship between the body’s structure and function and recognizes the body as an integrated system. Doctors of Osteopathic Medicine (DOs) take a whole-person approach to patient care, focusing not only on specific symptoms or diseases but also on the interaction among the body’s various systems.
One of the distinctive treatment approaches used by DOs is osteopathic manipulative treatment.
Osteopathic Manipulative Treatment and Physiologic Function
OMT consists of hands-on techniques used to prevent, diagnose, and treat illness or injury. These techniques may address structural and functional problems involving the bones, joints, muscles, fascia, and other tissues.
Common OMT techniques include:
- Active method
- Counterstrain
- Functional method
- Indirect method
- Myofascial release
- Cranial manipulation
- Percussion vibrator technique
- Visceral manipulation
OMT is a noninvasive, medication-free treatment that may be used for a variety of musculoskeletal and other conditions. Depending on the patient and clinical circumstances, it may be incorporated into the management of conditions such as headaches, arthritis, fibromyalgia, carpal tunnel syndrome, sports injuries, sinus-related problems, vertigo, and other conditions.
Because many OMT techniques are gentle, they may be appropriate for patients across a broad range of ages when clinically indicated.
Establishing the Diagnosis and Treatment Approach
Patients do not necessarily present to a DO solely to receive OMT. In many cases, an E/M service is required to evaluate the patient’s presenting concern, obtain an appropriate history, perform an examination, and establish or reassess a diagnosis.
The osteopathic examination may include evaluation of the neuromusculoskeletal system and its relationship with other body systems. When assessing for somatic dysfunction, the physician may identify findings commonly summarized by the acronym TART:
- T — Tenderness
- A — Asymmetry
- R — Restriction of motion
- T — Tissue texture abnormality
Somatic dysfunction in one region may also contribute to compensatory dysfunction elsewhere in the body. The physician therefore evaluates the patient as an integrated whole rather than limiting the assessment to a single body system.
ICD-10-CM codes for somatic dysfunction are organized according to the affected anatomical region:
- 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
- M99.07 — Segmental and somatic dysfunction of upper extremity
- M99.08 — Segmental and somatic dysfunction of rib cage
- M99.09 — Segmental and somatic dysfunction of abdomen and other regions
The appropriate diagnosis code should correspond to the regions of somatic dysfunction identified during the examination.
OMT and the E/M Service
OMT is performed to address identified somatic dysfunction and improve musculoskeletal and physiologic function. Unlike some other forms of manual therapy, OMT does not necessarily involve a predetermined treatment plan that is repeated at every visit.
At each encounter, the DO determines whether OMT is clinically appropriate based on the patient’s current condition. The physician may treat different regions and use different OMT techniques depending on the findings identified during that visit.
OMT may also be provided alongside other medical services. For example, the physician may manage medications, recommend exercises or breathing techniques, provide additional treatments, or refer the patient to another specialist.
Coding Considerations
The key coding issue is whether a separate and identifiable E/M service was performed in addition to the OMT.
When medically necessary and appropriately documented, an E/M service may be reported on the same date as OMT with modifier 25, which indicates that the E/M service was significant and separately identifiable from the procedure.
Importantly, the presence of a separate diagnosis is not necessarily required to report both an E/M service and OMT on the same date of service. The critical consideration is whether the E/M service is separately identifiable, medically necessary, and supported by the medical record.
The OMT CPT® codes 98925–98929 represent the OMT procedure itself. The physician should therefore ensure that documentation clearly distinguishes the E/M work from the work performed as part of the OMT procedure.
Understand Payer-Specific Coverage Requirements
Coverage policies for OMT can vary among payers. Some payers have established specific policies addressing OMT and the circumstances under which an E/M service may be reported on the same date.
For example, certain payer policies recognize that an E/M service may be separately payable when it is medically necessary and appropriately documented. However, other policies may apply different requirements to planned or routine follow-up OMT visits.
A key distinction is whether the encounter is a predetermined OMT follow-up or whether the patient presents for evaluation of a new problem or a significant change in an existing condition.
For planned, routine OMT follow-up visits, some Medicare Administrative Contractor and commercial payer policies may not support a separate E/M service unless a new condition develops or the patient’s condition has changed sufficiently to require a separate evaluation.
Because payer policies can change and may differ by plan and jurisdiction, providers should verify the applicable coverage policy before submitting claims.
Documentation Must Support Medical Necessity
Accurate documentation is essential when billing both an E/M service and OMT. The medical record should clearly establish the medical necessity of each service.
Documentation should generally demonstrate:
- The medical necessity of both the E/M service and OMT.
- Appropriate examination findings supporting the diagnosis of somatic dysfunction.
- Relevant findings involving skeletal, arthrodial, myofascial, vascular, lymphatic, or neural structures.
- At least one TART finding for each region of somatic dysfunction treated.
- A clear correlation between the documented somatic dysfunction and the regions treated with OMT.
- The specific OMT technique or techniques performed for each treated region.
- Objective information demonstrating functional improvement, decline, or other relevant changes, particularly when managing chronic conditions.
- An appropriate history and examination identifying new problems or significant changes in established conditions when applicable.
- Documentation demonstrating that the E/M service was separately identifiable from the OMT procedure when modifier 25 is reported.
Conclusion
Proper OMT coding requires more than simply documenting that manipulation was performed. Providers must demonstrate the clinical reasoning behind the evaluation, diagnosis, and treatment, while clearly distinguishing the E/M service from the OMT procedure.
Although thorough documentation does not guarantee that every payer will process a claim correctly, it provides important support for medical necessity and helps demonstrate compliance with applicable coding and coverage requirements.
Ultimately, reducing OMT-related denials depends on three key elements: understanding the clinical purpose of OMT, applying the appropriate coding principles, and following the specific requirements of the patient’s payer.