Osteopathic Billing & Coding

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The following ICD-10 codes should be used for proper OMT billing:

• 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

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The chart below contains the work value for OMT codes 98925-98929:

To accurately report E/M and OMT as separate services, they must be provided on the same date by the same physician. When documenting, it is important to understand how both services are connected, but why OMT should be separate from the E/M service.

• OMT is a manual treatment associated with musculoskeletal pain conditions and/or its effects on other body systems.

Patients typically present to the physician on the initial encounter to address acute problems and on subsequent encounters for re-evaluation and ongoing care, which may be related to the initial problem.

An E/M service is necessary to address the presenting problem, followed by the physical exam and if somatic dysfunction is found that is included in the plan of the E/M visit.

Modifier -25 allows for separate reporting for E/M and OMT services provided on the same date for initial and subsequent encounters.

Report the appropriate CPT E/M service (99202-99215) code and the appropriate OMT code (98925-98929). Append Modifier -25 to the E/M service code.

Documenting E/M Service:

Document the patient’s chief complaint or reason for encounter, a pertinent history and examination, assessment and plan for that E/M encounter. Tell the “story” of the encounter. Be specific when documenting your TART findings within the E/M.

The 2021 E/M coding and guidelines changes allow for the level of service to be determined by either medical decision making or time.

CMS MLN Evaluation & Management Services Guide

Documenting OMT:

OMT is considered a minor procedure and should be documented as such.

• Patient decided to proceed with recommended OMT today to treat the somatic dysfunction found in today’s physical exam.
• Document consent obtained
• Put in “specific position” to treat “area” “technique used” for each region treated
• Region(s) identified during the exam diagnosed with but not limited to somatic dysfunction or disorders in the skeletal, arthrodial, myofascial and visceral structures as well as related vascular, lymphatic and neural elements
• Specific segmental dysfunction areas being treated
• Compensatory changes and rational for treating
• Patient toleration of the procedure
• Post care instructions given

Documentation tips:

• Always separate your E/M services from the procedure note. Your documentation should identify that a separate and significant E/M was performed the same day as the OMT.
• Always precede OMT with E/M that clinical supports the medical necessity for the services.
• Never bill more than one E/M service per physician per day.
• Never use modifier -59 instead of modifier -25.

Medically Necessity MUST be Met

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:

• The medical record should support the medical necessity of the E/M service as well as the osteopathic manipulative treatment.
• The documentation should clearly identify the body regions affected and treated with OMT to justify the procedure code billed and the medical necessity of the service being performed
• Documentation of examination findings of somatic dysfunction should describe pathology in the areas of the skeletal, arthrodal and myofascial structures as well as related vascular, lymphatic and neural elements when present. One or more of the elements of TART should be specifically documented (what were the tissue changes, ROM etc.) in each region of somatic dysfunction to be treated with OMT. The selection of body regions to which OMT is to be applied should reflect the regions of documented somatic dysfunction
• There may be instances when multiple regions are treated due to the presence of compensatory changes. When this occurs, the documentation should describe the compensatory changes and the rationale for treating this area. The type, frequency, and duration of OMT should be consistent with current standards of medical practice.
• 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 true for the treatment of somatic dysfunction in patients with chronic, persistent 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) 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 AOA’s recommendation as a leading authority in osteopathic medicine.

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.

Payers often believe the E/M service is included as a component of the OMT procedure or that there is an overlap in expenses between the E/M and OMT as justification for payment denial. However, the Relative Value Scale Update Committee (RUC) and Centers for Medicare and Medicaid Services (CMS) have adjusted reimbursement for CPT codes typically reported with E/M codes for any overlapping costs. The RUC specifically discussed the pre and post service physician work associated with OMT CPT codes 98925-98929 and determined the time for the pre and post service physician work is distinct from the separately reportable E/M service reported on the same day as the relevant OMT code. In the 2012 Medicare Physician Fee Schedule Final Rule, CMS refined and finalized the physician time requirements and the associated Relative Value Units (RVUs) for the OMT codes to not include E/M services, confirming the position that the physician work for OMT and E/M are separate and distinct.

Moreover, if evaluating the work RVUs between E/M services and OMT procedures, the RVU values alone indicate there is not an overlap between the work. For example, if comparing CPT codes commonly performed on the same date of service, E/M 99213 with a work RVU of 1.30 to OMT procedure 98926 3-4 regions with a work RVU value of .71, the OMT is -.59 RVUs less than the 99213 E/M. If the 99213 E/M service were included in the 98926 OMT procedure we would expect the OMT work RVU to be greater than the E/M work RVU and it is not. The work RVU values assigned to E/M and OMT codes further confirms the position that there is not an E/M component included in the OMT.

Pay Attention to Coverage Guidelines

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.

Some payers, from CMS to United Healthcare, have well-established coverage policies on OMT. Visit  Private Payer News to view several that may impact your practice.

CMS local coverage determinations (LCD) article A56954 states that “If a significant, separately identifiable evaluation and management service above and beyond the osteopathic manipulation service is provided, this must be indicated by reporting modifier 25 to the E&M service code. 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 a follow-up visit where OMT is utilized is not necessarily predetermined unless the preceding progress note denoted it to be an OMT visit.”

Medicare Administrative Contractor NGS states in their coverage guidelines for OMT (LCD ID L33616) that no E/M service is warranted for previously planned follow-up OMT treatments unless a new condition occurs, or the patient’s condition has changed substantially, necessitating an overall reassessment of the treatment plan.

LCD A 55318 provides responses to related to Osteopathic Manipulative Treatment that may be of interest.

Learn more tips for managing your practice with these available practice related webinars offering CME credit.