Gain Insight Into Billing an E/M With OMT


Reducing denials starts with understanding osteopathic manipulation as well as coding and coverage guidelines for this therapy.

Is it appropriate to bill an evaluation and management (E/M) service when osteopathic manipulative treatment (OMT) is performed at the same visit? We must address a few key principles to adequately answer this question. I learned quickly, having spent 10 years managing a medical practice specializing in osteopathic manipulative medicine (OMM), that this specialty can often be an enigma, even to seasoned medical coders and auditors. I found that OMT, a treatment utilized by physicians specializing in OMM, may not only be misunderstood by patients but also widely misunderstood by many payers. It is important to understand the foundations of OMT to properly code and bill for these services.

What Is Osteopathic Medicine?

Osteopathy is a branch of medicine emphasizing physical manipulation of the body’s muscles and bones and the interrelated unity of all systems in the body, working synchronously to heal in times of illness. Doctors of Osteopathic Medicine (DOs) believe that the state of good health goes beyond the absence of disease or pain. The philosophy behind 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 medicine, treating the entire person rather than just the symptoms.

OMT to Improve Physiologic Function

A common treatment technique utilized by DOs is OMT, a set of manual techniques used to prevent, diagnose, and treat illness or injury. OMT can be used to treat structural and functional issues in the bones, joints, tissues, and muscles of the body. Additionally, OMT uses the interconnected relationship between the neuromusculoskeletal system and other body systems to promote whole-person healing.

There are many different forms of OMT including:

  • Active method
  • Counter strain
  • Functional method
  • Indirect method
  • Myofascial release
  • Cranial manipulation
  • Percussion vibrator technique
  • Visceral manipulation

OMT is a medication-free, noninvasive treatment option 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 issues, OMT is also an excellent treatment option for chronic sinusitis, vertigo, acid reflux, anxiety, depression, post-concussion syndrome, and the list goes on. Because most forms of OMT are so gentle, it is suitable for patients of all ages, from newborns to adults. In fact, 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 therapy, meaning that there is an energetic connection between the patient and physician when OMT is performed.

Determining a Diagnosis and Treatment Plan

Patients generally do not present to a DO solely for the purpose of receiving OMT. An E/M service is typically necessary to learn about and address the presenting problem, which includes the DO performing a physical examination to help determine a diagnosis. A structural diagnosis involves the use of inspection, observation, and palpation to examine the neuromusculoskeletal system and its interactions with the cardiovascular, lymphatic, and pulmonary systems.

A diagnosis of somatic dysfunction is made by identifying the presence of one or more of the following findings — tenderness, asymmetry, restriction of motion, tissue texture change/abnormality — commonly known by its acronym TART. Somatic dysfunction in one region can create compensatory dysfunction in another body region.

Examinations performed by osteopathic physicians are not limited to certain body systems. The goal is to identify impediments in health, including, but not limited to, somatic dysfunction. Somatic dysfunction refers to impaired or altered function of related components of the body framework. ICD-10-CM codes are broken down by body region and should be applied based on the identified areas of somatic dysfunction.

  • 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

OMT is used to treat somatic dysfunction by normalizing musculoskeletal activity, thereby normalizing sympathetic and parasympathetic nervous system signaling to the viscera, resulting in more normal body system functioning. Typically, a treatment plan is not created for OMT. 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.

The DO determines at each visit whether OMT is appropriate therapy for the presenting problem and may utilize different forms of OMT on different body regions. OMT may also be accompanied by other treatment modalities. It is not uncommon for osteopathic physicians to prescribe and manage medications, suggest exercises, teach breathing techniques, refer to other specialists, or even perform trigger point injections.

Coding Considerations

It has long been the position of the American Osteopathic Association (AOA) that an osteopathic physician should report an E/M service with modifier 25 Significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service appended for 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 and the American Academy of Osteopathy have affirmed the AOA’s position that an E/M service should be billed at the same visit as OMT.

The CPT® introductory language for the OMT codes specifies that modifier 25 is used to indicate 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 five OMT CPT® codes (98925-98929) was reviewed by the RVS Update Committee (RUC) Advisory Committee. The committee recommended that the practice expense include only the work of the OMT procedure itself. Translated, there is no E/M included in OMT. These recommendations were adopted by the Centers for Medicare & Medicaid Services (CMS) in 2003 and hold true today.

Pay Attention to Coverage Guidelines

Some payers, from CMS to United Healthcare, have well-established coverage policies on OMT, while others still have a gross misunderstanding of this treatment. I have worked with many private payers that, upon claims processing, inappropriately apply covered OMT services to physical therapy or chiropractic benefits. The AOA’s physician services team engages with private payers to advocate on behalf of physicians to decrease administrative burden, streamline payment of claims, and improve patient outcomes. They work directly with private payers when coverage policies delay payment or impede patient care.

Payers like UnitedHealthcare have published coverage policies that indicate a broader understanding of this treatment. The policy published by UnitedHealthcare 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 local coverage determinations (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 during which OMT is utilized is not necessarily predetermined unless the preceding chart note indicates the visit is an OMT visit. Medicare Administrative Contractor CGS states in their coverage guidelines for OMT (article A52435) 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 UnitedHealthcare’s OMT coverage guidelines.

Prove Both Services Were Medically Necessary

To adequately support the medical necessity of OMT as well as the E/M service, the documentation requirements, regardless of payer, all essentially state the same requirements must be met:

  1. The medical record should support the medical necessity of the E/M service as well as the osteopathic manipulative treatment.
  2. Exam findings documentation of somatic dysfunction should describe pathology in the areas of skeletal, arthrodial, and myofascial structures as well as related vascular, lymphatic, and neural elements.
  3. One or more elements of TART should be documented for each region of somatic dysfunction treated with OMT.
  4. The selection of regions to which OMT is applied should reflect the regions of documented somatic dysfunction.
  5. The type of OMT used on a region should be clearly documented.
  6. Functional improvement or decline should be documented using objective measures. This is especially important when addressing chronic conditions.
  7. The clinically appropriate history and exam of the patient should identify any new conditions, if present, or if the patient’s established condition(s) has/have changed substantially, necessitating an overall assessment.

While implementing the above documentation requirements does not guarantee that payers will accurately process claims billed with an E/M service when provided with OMT, it does ensure that your documentation complies with well-established payer coverage guidelines and the recommendations of the associations known to be the leading authorities in osteopathic medicine.

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