OMT Coding Strategies to Boost Your Bottom Line
Implement these strategies for better OMT reimbursement.
By Douglas J. Jorgensen, DO, CPC
Keeping osteopathic manipulation as part of a busy family practice may at times seem arduous and frustrating.
However, the benefits to patients and to your bottom line far outweigh the perceived barriers to making Osteopathic
Manipulative Treatment (OMT) part of your daily practice, both in and outpatient.
With key input from Dr. Edward G. Stiles, a small teaching hospital in central Maine helped put osteopathy on the
federal map. In 1974, Medicare contacted Dr. Stiles due to the objective lack of repeat admissions and improved
outcomes for their patients based on billing patterns that proved these measures. 1 When queried, osteopathic
medicine with OMT having a vital role was the answer for those better than average outcomes and thus, federal
acceptance of OMT commenced.2
In today’s fast-paced practice setting, we often see decreased reimbursement for patient encounters. The solution
suggested by both payors and administrators to this problem is to maintain last year’s numbers by seeing more
patients. OMT helps treat a myriad of diseases and complaints, but also allows physicians more quality time with
patients so they can have medically relevant discussions about their disease, prognosis, psychosocial issues, and
treatment options. As if this were not enough, physicians can be paid for a procedure that is and should be readily
reimbursed along with the office visit.
Bundling
The American Medical Association (the publishers of Current Procedural Terminology (CPT)) has affirmed the AOA’s,
the AAO’s and the ACOFP’s position that Evaluation and Management (E&M, a.k.a. inpatient or outpatient visit codes)
and OMT codes (98925-98929) can and should be billed at the same visit.3
Moreover, it can be done for the same or similar diagnoses assuming both E&M and OMT occurred with medical
necessity and documentation supporting their use. In other words, OMT and an office or hospital visit are not bundled.
E&M does not include OMT and OMT does not include E&M. If you did both and documented it, you should be paid for
both.
The only instance you should be paid for OMT alone is if that was the sole intent of the visit and you specifically
outlined in your prior note that you would be performing OMT at the next visit for a predetermined problem. If no new
problems or issues were discussed at the next visit, OMT codes should only be billed as you designate that visit for the
OMT procedure, no differently than you would designate a visit for a mole removal, and only charge for that. Therefore,
be clear in your discussions of therapeutic interventions and options.
If you need to reevaluate the patient at the next visit before determining if OMT is necessary, simply put ‘follow up for
reevaluation’ or ‘follow up for reevaluation and possible treatment.’ Either suffices as they clearly state you need to
assess the situation before determining a treatment course.
Therapy vs. Treatment
In terms of treatment options, it is imperative that we are consistent in our terminology. Semantics matter and as
physicians we provide treatment not therapy. A few years ago a prominent payor took a stance nationally to deny
payment for craniosacral therapy. This was likely done, in large part, to halt therapists’ reimbursement for craniosacral
therapy. However, OCF or osteopathy in the cranial field is not therapy, but treatment and is still readily reimbursed.
Cranial osteopathy, like high velocity, muscle energy treatment, and/or myofascial release, is a treatment option
osteopathic physicians can and should use. However, when called upon to help resolve payor/ payee issues, I am
often confronted with members of the DO and MD community calling OMT, osteopathic manipulative therapy. 4
Therapy it is not and this term should primarily be relegated to physical, occupational and/or massage therapists or
any other practitioner doing therapy. Physicians provide treatment.
Using -25 vs. -51 vs. –59 Modifiers
When billed together, OMT and E&M necessitate use of the –25 modifier on the E&M code. The definition of the -25
modifier, that is a significant, separately identifiable evaluation and management service by the same physician on the
same day of the procedure or other service, suggests that the diagnosis must be different. 5
However, as detailed above, with OMT and E&M that is not the case. If you perform OMT in addition to an office visit,
you simply do your usual note with a structural exam in the objective. See Table 1.
Notice the history is seemingly short, but is detailed per
CPT (four elements in History of Present illness (HPI), two
– nine Review of System (ROS), plus two of the family,
medical and/or social histories for an established patient).
The physical exam is detailed too (using 1995 Federal
Documentation guidelines five-seven examined areas)
and the A/P or Medical Decision Making is moderate
complexity based on the diagnosis of new problems with
pharmaceutical management. Thus, this would be billed
as a 98928 (eight areas, thorax, ribs, lumbar, pelvis,
sacrum, lower extremity, cervical and abdomen) and a
99214-25.
For most payors, they want the procedure listed first with
correlative diagnoses (International Classification of
Diseases or ICD-9 codes) listed first too. This can be
regionally variable for in some areas in the Midwest, the
payors want the nonsomatic dysfunction ICD codes first
and the 729 (somatic dysfunction) ICD codes last. In that
case the E&M code would be listed first and OMT codes
second. This is atypical, but again speaks to payor
variability.
In the example, the history and exam were done as part of
the office visit and it was not until you made the medical
decision to perform a procedure that OMT came into the
picture. The Assessment and Plan (A/P) outlined what OMT techniques were used and the first A/P is essentially the
procedure note.
The structural exam, although a descriptor of what was treated, is really the part of the note creating medical necessity
to justify the procedure performed as well as A/P two, three and four’s interventions. It is not just done for OMT, but is
vital to the E&M visit too. Thus E&M with this visit or similar encounters is appropriate.
If during the examination you find areas that need injections in addition to the OMT, this would add another level of
complexity. Performing OMT with an iliocostalis thoracic trigger point injection (TPI) and an upper pole SI injection,
would require a modifier on the procedures and the E&M. They would be coded as 20550 (Ligament Injection), 2055259
(1-2 Trigger Point Injections with a –59 modifier) and 98928-51 (OMT with a –51 modifier) and perhaps a 99213-25.
The first procedure needs no modifier and you want to list the most complex (a.k.a. the best reimbursed) procedure
first. Then code the next most complex procedure, then the next, etc. OMT is typically reimbursed less than injections
so it would be listed last in the above procedure example if injections occurred also.
The –59 modifier represents a distinct procedural service.6 While it should not be overused, the –59 modifier is
particularly helpful in this instance for it says to the payor, “wait, this is distinct and you should pay for this additionally.”
This is especially important using 20552 and 20553 with other injections.
In 2002, TPIs were given added clarity with 20552 designating 1 or 2 TPI and 20553 for > 3 TPI. 7 Due to this change
and subsequent software edits, many payors deny multiple injections when the 20552 or 20553 injection codes are
done at the same visit. In the above example -59 modifier helps resolve that by saying this is separate and distinct
from the 20550, especially since 20552 could be interpreted by the payor as one or two muscles being injected.
For many payors they assume you are doing TPIs, and not specifically injecting ligaments or tendons (e.g.: 20550 and
20551, respectively; tendon sheath, not tendon, is still coded 20550) on all your injections if you bill a 20552/20553
with any other injection procedure. This is particularly problematic if all the injection sites are in one body area like the
shoulder.
For instance, injecting the coracoclavicular ligament, the proximal biceps tendon and the belly of the medial deltoid
would be charged 20550, 20551 and 20552, respectively. A –51 modifier should be all that is needed on the 20551
and 20552, but the –59 modifier gets the point across that these are three distinct injections and you want to get paid
for each individually. The –51 modifier above represents multiple procedures and lets them know to be looking for
more than one procedure. Although initially confusing, these modifiers are pretty straightforward to use. You will need
to watch your denials and pay attention to which payors need the –59 vs. those that will accept the –51 modifier.
Bundling with E&M.
One of the more common payment problems I have seen is a primary care provider who is told by his insurer that as a
participating provider his OMT services are part of their capitation agreement or are bundled with any E&M service.
The latter is more easily addressed for we have good evidence from the AOA legal department as well as precedent
on our side.
The capitation arguments usually go back to the contractual arrangements set up by the practice. Regardless of
whether your practice or Physician Hospital Organization did the contracting, you can bring it up at your renewal
meeting. You simply need to make sure those representing you understand the OMT/E&M issues.
Fee for service reimbursement, in my opinion, is your best option, especially for procedures. Some payors may agree
to that, but then try to pay you the same for 98925 as a 98928 stating they are both OMT.
You need to have them spell out your reimbursement and to show incremental increases to represent the work being
done on increasingly more areas as you move from 98925 to 98929. These matters should be settled in writing before
signing your agreements. An experienced, healthcare attorney should oversee this and your renegotiations at an
annual renewal meeting. It is well worth the time and money.
Capitation
If you opt to join a capitated system and they want to include OMT, you need to make certain you are getting more per
patient than your counterparts who do not perform OMT. You can argue that this service will limit chiropractic and
physical therapy utilization, decrease and shorten hospitalization and is an added service making you a preferred
choice by many plan participants.
Getting capitated for OMT really should be a last resort and an analysis of what you would be getting fee for service
needs to be done before you agree to a monthly stipend per patient. Without this analysis based on how much
manipulation you do, you cannot adequately determine what the worth of that service is under a capitated system. If
they choose to capitate this service and not mole removals or toenail surgery, you might argue discrimination.
Therefore, as with all contract negotiations, consult and utilize an experienced healthcare attorney.
Chiropractic Associations
In certain regions OMT is denied secondary to lack of membership in the local Chiropractic Association contracted with
that payor for manual manipulation. Even when DOs tried to join so they could be paid for OMT, the door was not open
as they were not graduates of a chiropractic college, a stipulation of membership. Unfortunately, private payors are
allowed to make their own rules. Thus, to date, many of these situations have not been resolved favorably.
However, citing denial of access to medically necessary healthcare, certain regions affected might be able to fight this
en mass. Patients can and should be their own advocates. The employees at your state bureau of insurance are tax
paid employees who can assist you and your patients with access issues where other means have failed. Furthermore,
state and federal legislators can and will listen to patients denied access to healthcare and this election year,
healthcare access for patients is a hot topic. To date this issue has been challenging and if you face a similar situation,
bring it to the attention of your state osteopathic society and the AOA.
Appeals
My second year pathology professor was fond of saying “if you don’t look for it you won’t diagnosis it.” Seemingly
simplistic, but sage never the less. If you don’t resubmit, you won’t get paid is equally simple, but true advice. MGMA
did a mid 90’s study that revealed on average only 50 percent of denials are resubmitted.
In some instances, payors may routinely deny a code with just this expectation in mind. However, if you resubmit even
once (but occasionally more than that) you often get paid. Precedence set by prior payment patterns can be sited to
prompt payment.
You can change your modifiers if that potentially will help you or you may need to call and ask what the problem is.
Often times the denial code outlines their problem with your claim and sometimes they simply make no sense.
However, to not resubmit is giving away money you deserve. OMT pays well, but you must be persistent with certain
payors.
The number of diagnoses alone exceeds most typical office visits (98928 is 7-8 ICD codes for OMT and then, if you do
an E&M there are 2-3 of those typically too) and this far exceeds the four spaces for ICD codes on the HCFA 1500
forms used by Medicare and some private payors. Thus, without submission of your notes, they might not fully
understand what you did at the visit.
Once a payor gets used to your office and how you do claims, typically things improve. Others will be seemingly
difficult on all counts and you will need to know the rules, enforce them and, if necessary request a formal investigation
by the bureau of insurance for private payor matters.
Your state medical society may be aware of similar issues and can potentially set up a meeting or make a call on
behalf of ‘a member’ to keep it anonymous and hopefully amicably resolve matters.
It should be noted that Medicaid and Medicare are not under the jurisdiction of the state bureau of insurance. To file a
complaint there you have to go to your regional Center for Medicare and Medicaid Services (CMS) or to your regional
Medicare Carrier or your state’s bureau of medical services. Fortunately, in the case of Medicare and Medicaid, they
are typically consistent in their reimbursement policies, even if we are not happy with the reimbursement itself.
Documentation of OMT
Poor documentation, even if the work was done at the patient visit, is the primary issue for penalties imposed by
audits. Audits aside, notes are often requested to clarify what actually transpired and this is your only record medico
legally as well as to defend your charges billed. While an exhaustive medical student or resident note is impractical, we
need to be consistent in our terminology and documentation.8
For vertebral somatic dysfunction, the gold standard should be describing the three planes of motion:
1. neutral, flexion or extension
2. side bending
3. rotation
Brevity is best so writing T4-6NRLSR clearly illustrates that the fourth through sixth thoracic vertebrae were in neutral,
rotated left and side bent right. Writing T4-6 with a left convexity essentially conveys the same principle, but is less
specific and more open to interpretation. Make your notes unambiguous and write exactly what you mean. The less
there is to interpret, the more likely you can validate work done and subsequently obviate reimbursement.
Several texts and our terminology from OP&P and OMM during our DO training speak to how we are to document
OMT. A quick review or refresher course might be all that is needed to improve documentation to ensure proper
reimbursement.
Consultant Issues (99241-99245)
Some payors are fond of disallowing primary care providers from being consultants despite the inconsistency with their
own policies allowing you to consult on your surgical patients pre and postoperatively. Consults for musculoskeletal
and/or neurologic pain should be an active part of any osteopathic family doctor’s inpatient and outpatient practice.
Consults pay better than new patient codes (9920199205) and you can do them within your existing practice
too from associates’ patients who you do not routinely
see.
If a referral is needed, even if it is in your own office,
make sure it is done. Payors may not be used to a family
medicine specialist doing consultative duties, but it is no
different than an internist who is not a cardiologist giving
their opinion to a colleague or a pediatrician with an
interest in behavioral medicine, but not subspecialty
training, giving his or her thoughts and treatment
suggestions to the referring provider. The usual
consultative rules apply.9 See Table 2.
Remember, you need not be an expert to be a consultant, you need only be able to offer a service that others would
find potentially helpful and let patients and colleagues know of your area of interest.
Summary
OMT is a wonderful addition to your treatment options that can provide an added economic boost to your bottom line.
Knowing your payor mix, how to document and code correctly as well as what modifiers to use when will allow more
consistent, optimal reimbursement.
Spending more quality time with patients, holistically treating their ailments and being paid for it makes this a truly
rewarding procedural experience.
Douglas Jorgensen, DO, CPC is a family physician with Manchester Osteopathic Healthcare in Manchester, Maine. He
is a Certified Professional Coder, and the founder of Jorgensen Consulting, a national professional service
organization offering educational forums and coding consultation. He can be contacted via e-mail at
drj@jorgensenconsulting.net.
References:
1. Letter dated 7/30/74 from David D. Williams, Manager Medicare Benefits and Administration, Medicare, Part B to
Edwards G. Stiles, D.O. in Waterville, Maine. Dr. Stiles is currently at the Pikeville College School of Osteopathic
Medicine and serves as Professor of Osteopathic Principles and Practice and Chair, Department of Osteopathic
Principles and Practice.
2. Personal communication with Dr. Stiles
3. February 2004 CMS Physician’s Regulatory Issues Team (PRIT) www.cms,hhs.gov/physicians/prit/issues.asp. All
regional carrier directors agreed to this policy.
4. Note CPT does not designate OMT to Dos only. MDs. Pas, NPs, can bill for OMT if it is within the scope of their
practice despite objections by many Dos. DCs must use DC codes and PT/OT must use their codes, as they do
not have full scope of practice privileges in most settings. Physicians and mid-levels (PZ/NP) can use whatever
CPT codes best describe the service or procedure provided and the only limits on those are state and federal
licensing as well as privileges n a more local level.
5. Jorgensen, DJ; “Consistency for OMT Coding”; Osteopathic Family Physician News; April 2003.
6. Gordy, K. Ed.; Current Procedural Terminology 2004; American Medical Press; Chicago; p.; 2003
7. Jorgensen, DJ; “New Injection Codes for 2002”; Osteopathic Family Physician News; June/July 2002.
8. Jorgensen, DJ; “Consistency Counts for OMT Coding”; Osteopathic Family Physician News; April 2003.Ibid