Local Coverage Determination (LCD)

Osteopathic Manipulative Treatment

L33616

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Contractor Information

LCD Information

Document Information

LCD ID
L33616
LCD Title
Osteopathic Manipulative Treatment
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL33616
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 11/21/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
09/16/2016
Notice Period End Date
10/31/2016
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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.

Current Dental Terminology © 2021 American Dental Association. All rights reserved.

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CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862(a)(7) excludes routine physical examinations unless otherwise covered by statute.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract

Osteopathic manipulative treatment (OMT) is a distinct manual procedure employed by physicians, that aims to optimize a patient’s health and function. OMT is defined in the Glossary of Osteopathic Terminology as the therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. OMT encompasses a wide variety of techniques, including but not limited to muscle energy, high velocitylow amplitude, counterstrain, myofascial release, visceral, articulatory, and cranial. The chosen treatment will vary depending on patient’s age, clinical condition and the effectiveness of prior methods of treatment. (Note: OMT is appropriately provided by a D.O. or by an M.D. who has been trained in OMT.)

Somatic dysfunction is defined in the Glossary of Osteopathic Terminology as impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements.

Indications
Osteopathic Manipulative Treatment is covered when medically necessary and performed by a qualified physician, in patients whose history and physical examination indicate the presence of somatic dysfunction of one or more regions (appropriately documented in the medical record) when such treatment is likely to result in improvement in the patient’s condition (e.g. less pain) or functional status. The diagnosis of somatic dysfunction is made by determining the presence of one or more findings described by the acronym TART (Tenderness, Asymmetry, Restriction of Motion and Tissue Texture Abnormality).

Somatic dysfunction in one region can create compensatory somatic dysfunction in other regions. Osteopathic manipulative treatment is also utilized to treat the somatic component of visceral diseases. This component can manifest as changes in the skeletal, arthrodial and myofascial tissues. (e.g., right shoulder pain and associated somatic dysfunction in a patient with gallbladder disease).

Note: Osteopathic Manipulative Treatment specifically encompasses only the procedure itself. E&M services are covered as a separate and distinct service when medically necessary and appropriately
documented. 

 
Limitations
Osteopathic Manipulative Treatment is not covered when the indication of Coverage is not met, and conventional documentation of somatic dysfunction is not present in the patient's medical record.

No E&M service is warranted for previously planned follow-up OMT treatments.
Examples include:

  1. If a patient is scheduled for a defined number of follow-up OMT treatmentsfor an episode of care, no E/M should be reported on those dates of service unless a new condition occurs or the patient’s condition has changed substantially, necessitating an overall reassessment of the treatment plan;
  2. If a patient is seen and the E/M service determines that OMT is indicated, but the patient must be scheduled to receive the OMT the following day due to time constraints, no E/M should be reported on the following day unless the patient’s condition has changed substantially. The medical record should clearly document this.

 

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information
N/A
Sources of Information
This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

NHIC LCD L3206, Osteopathic Manipulative Treatment, last updated May 12, 2011.

D’Alonzo, GE, Ed; American Osteopathic Association Glossary of Osteopathic Terminology 1998:816.

First Coast Service Options Inc. LCD retired L29246, Osteopathic Manipulative Treatment, last updated February 2, 2009.
Bibliography

N/A

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
11/21/2019 R3

This LCD was converted to the new "no-codes" format. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
09/01/2019 R2

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A56954. There has been no change in coverage with this LCD revision.

  • Provider Education/Guidance
11/01/2016 R1 This LCD was revised and returned to Jurisdiction 6 and Jurisdiction K for public and CAC comment from 06/30/2016 through 08/13/2016.
Changes were made in the Indications section to add the definition of somatic dysfunction, and its relation to different body regions. The Limitations section was revised to add examples of situations where separate E&M services are not warranted.
The Documentation Requirements section was revised to add specific findings that should be included in the record.
The Utilization Guidelines section was revised to add detailed treatment guidelines for acute, sub-acute and chronic phases of OMT.
  • Provider Education/Guidance
  • Public Education/Guidance
  • Aberrant Local Utilization

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
11/14/2019 11/21/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • OMT

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