This article contains coding and other guidelines that complement the local coverage determination (LCD) for Osteopathic Manipulative Treatment.
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:
Outpatient evaluation and management (E&M) services (CPT codes 99201-99205, 99211-99215, etc.) are National Correct Coding Initiative (NCCI) column 2 codes to the OMT service CPT codes (98925-98929).
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, the E&M services are only separately allowed when there is a significant, separately identifiable E&M service.
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.
- 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.
- Only one OMT service should be billed per day, based on the description of the procedure code.
- The type, frequency and duration of services must be reasonable and consistent with the standards of practice in the medical community.
- 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:
- 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.
- 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.
- 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.
- 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.
- 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.