LCD Reference Article Billing and Coding Article

Billing and Coding: Osteopathic Manipulative Treatment

A56954

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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General Information

Source Article ID
N/A
Article ID
A56954
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Osteopathic Manipulative Treatment
Article Type
Billing and Coding
Original Effective Date
11/21/2019
Revision Effective Date
10/27/2022
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

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Article Guidance

Article Text

This article contains coding and other guidelines that complement the local coverage determination (LCD) for Osteopathic Manipulative Treatment.

Coding Guidelines:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient’s condition for which the service was performed.
 

Specific Coding Guidelines:

According to the NCCI Policy Manual for Medicare Services, Chapter I, General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services, E&M services are only separately payable with OMT services when there is a significant, separately identifiable E&M service.

Documentation Requirements

The medical record should support the medical necessity of osteopathic manipulative treatment as taught in the United States Osteopathic Medical Schools and made available to Medicare upon request.

The documentation should clearly identify the body regions affected and treated with OMT in order to justify the procedure code billed and the medical necessity of the service being performed. Medical records must be made available upon request.

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 (see above) should be documented in each region of somatic dysfunction treated with OMT. The selection of body regions to which OMT is 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.

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.

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.

Utilization Guidelines

  1. The number of regions treated during any one session will depend upon the history, examination and medical decision-making utilized to determine medical necessity of the most appropriate intervention. Each OMT service billed must include an indication of the patient’s pre and post treatment status.
  2. Only one OMT service should be billed per day, based on the description of the procedure code.
  3. The type, frequency and duration of services must be reasonable and consistent with the standards of practice in the medical community.
  4. Medicare defines the reasonableness of therapies based on the ability to "treat illness and improve function". If a response is not noted within a reasonable timeframe, by the physician, then other treatment options should be considered. The following are treatment guidelines and not rules:

 

    1. Acute phase OMT should be individualized and performed as necessary during the first month, but will typically be no more than once per week. If there is failure to progress then a re-evaluation of the patient and assessment of treatment and diagnostic considerations may lead to modifications.
    2. Subacute phase OMT should be performed as necessary to maintain the improvement trend but at less frequent intervals unless there are extenuating circumstances that are documented in the medical record. Once the patient’s condition has plateaued, any further treatment enters the chronic phase.
    3. Chronic phase OMT involves chronic illness or conditions (such as chronic pain syndrome with depression, postCVA spasticity, post-polio syndrome, progressive neurodegenerative disorders and malignant disease), and should be provided as necessary, for functional benefit, but is not expected to be more than one or two times per month unless explained in the medical record. It is the expectation that the patient’s ongoing symptomatology is adequately medically investigated if the treatment is protracted.
    4. It is understood that there can be exacerbations of chronic conditions, which can and should be treated to return the patient to a level of maximum functioning.
    5. It is appropriate to perform OMT on a patient who is hospitalized when the physician determines it is medically necessary to the patient’s treatment. The medical record should support this treatment decision.

 

Response To Comments

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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

Group 1

(5 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
98925 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); 1-2 BODY REGIONS INVOLVED
98926 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); 3-4 BODY REGIONS INVOLVED
98927 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); 5-6 BODY REGIONS INVOLVED
98928 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); 7-8 BODY REGIONS INVOLVED
98929 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); 9-10 BODY REGIONS INVOLVED
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CPT/HCPCS Modifiers

Group 1

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(10 Codes)
Group 1 Paragraph

The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the related determination.

Group 1 Codes
Code Description
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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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
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Other Coding Information

Group 1

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/27/2022 R1

Removed statement about NCCI edits that listed specific E&M codes.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L33616 - Osteopathic Manipulative Treatment
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
10/18/2022 10/27/2022 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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