OSTEOPATHIC MANIPULATIVE Treatment

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for OSTEOPATHIC MANIPULATIVE Treatment. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for OSTEOPATHIC MANIPULATIVE Treatment and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site. 

Internet Only Manual (IOM) Citations:

• CMS IOM Publication 100-08, Medicare Program Integrity Manual,
• Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD 

Social Security Act (Title XVIII) Standard References:  

• Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. 
• Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. 
• Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

History/Background and/or General Information 

OSTEOPATHIC MANIPULATIVE treatment (OMT) is a distinct manual procedure employed by a physician 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 have been altered by somatic dysfunction. There are numerous types of physician performed manipulative treatments that make up OMT. The method employed by the physician is determined by the patient’s condition, age and the effectiveness of previous methods of treatment. (Note: OMT can be performed by a D.O. or by an M.D. who has been specially 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. Somatic dysfunction is treatable using OMT. The positional and motional aspects of somatic dysfunction can also be described using at least one of three parameters: 

• The position of a body part as determined by palpation and in reference to its adjacent define structure,
• The directions in which motion is freer, or
• The directions in which motion is restricted.

The diagnosis of somatic dysfunction is made by determining the presence of one or more findings, known as T.A.R.T. (Tenderness, Asymmetry, Restriction of Motion and Tissue Abnormality). OSTEOPATHIC MANIPULATIVE treatment includes thrust (active correction), muscle energy, counterstrain, articulation, myofascial release, visceral and cranial technique. 

Somatic dysfunction in one region can create compensatory somatic dysfunction in other regions. OSTEOPATHIC MANIPULATIVE treatment can also be used to treat the somatic component of visceral disease and any organ system. This component can manifest as changes in the skeletal, arthrodial and myofascial tissues. (Example: tight right shoulder muscles in a patient with gallbladder disease). Normalizing musculoskeletal activity (relaxing tense muscles, etc.) can normalize outflows through sympathetic or parasympathetic autonomic nervous systems to visceral systems, resulting in more normal visceral and any organ system function.  

Definitions: 

The following is a more complete description of and examples of OMT techniques. Please refer to the AOAs Glossary of OMT terminology for more information. 

Thrust (active correction): Moving a restricted joint in the direction it is resisting. 

Example of Technique:
Physician slowly pulls joint in the direction it is resisting. Once at the point of muscle resistance, the physician continues to slowly pull against the muscle restraint, while applying a quick force localized to the area of resistance often resulting in a "pop" in the affected joint. 

Reason for Applying:
Treats motion loss and impaired or altered functions of the body’s framework. 

Effect of Treatment:
Immediate increase in range and freedom of motion. 

Muscle Energy: Manipulative treatment in which the patient’s muscles are actively used on request from a precisely controlled position, in a specific direction, and against a distinctly executed counterforce. 

Example of Technique:
The patient actively co-operates with the physician to contract a muscle or muscles, inhale or exhale, or move one bone of a joint in a specific direction relative to the adjacent bone. 

Reason for Applying:
Applied to strengthen weak muscles, activate inhibited muscles, and strengthen short, tight muscles. 

Effect of Treatment:
Mobilizes joints in which movement is restricted, stretches tight muscles and fascia, or fibrous tissue, that envelops the body beneath the skin, encloses muscles and groups of muscles, improves local circulation, and balances neuromuscular relationships to alter muscle tone and improve joint movement. 

Counterstrain: Technique in which patient is placed in position of comfort, maintains the position for a period of time, then is assisted by the physician to slowly return to a neutral position. 

Example of Technique:
Patient is placed in position of comfort for 90 seconds, then is slowly returned to a relaxed and neutral position. 

Reason for Applying:
Applied to relieve the physical pain of patients suffering from "tender points", to relieve referred pain from active trigger points and to normalize imbalances in the autonomic nervous system. 

Effect of Treatment:
Identifies tender points and positions the patient to eliminate the tenderness. 

Articulation: Physician gently and repeatedly forces the joint against the restrictive barrier, intending to reduce the barrier and improve motion. 

Example of Technique:
Physician moves the affected joint to the limit of all ranges of motion. As the restrictive barrier is reached, slowly, and firmly the physician continues to apply gentle force against the joint to the limit of tissue motion, or the patient’s tolerance to pain or fatigue. The articulation is slowly repeated several times, each time gaining increased range and improved quality of motion. 

Reason for Applying:
Most often applied to postoperative patients and elderly patients suffering from arthritis. 

Effect of Treatment:
Enhances the effect of passive articulating motion by resisting it or permitting increased range of motion. 

Myofascial Release: Also referred to as MFR, this procedure to designed to stretch and reflexly release patterned soft tissue and joint-related restrictions. 

Example of Technique:
Physician twists, shears, and compresses joints while simultaneously feeling tissue and joints for shifting tightness and looseness. 

Reason for Applying:
Applied to patients suffering from muscle tightness. 

Effect of Treatment:
Joint-related movements are assessed and treated simultaneously. Joint and muscle movements are improved and pain is decreased. 

The following is a complete description of Somatic Dysfunction. Please refer to the AOAs Glossary of OMT Terminology for more information. 

somatic dysfunction: Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using OSTEOPATHIC MANIPULATIVE treatment. The positional and motion aspects of somatic dysfunction are best described using at least one of three parameters: 1). The position of a body part as determined by palpation and referenced to its adjacent defined structure, 2). The directions in which motion is freer, and 3). The directions in which motion is restricted. See also T.A.R.T. See also S.T.A.R. 

acute s. d., immediate or short-term impairment or altered function of related components of the somatic(body framework) system. Characterized in early stages by vasodilation, edema, tenderness, pain and tissue contraction. Diagnosed by history and palpatory assessment of tenderness, asymmetry of motion and relative position, restriction of motion and tissue texture change (T.A.R.T.). See also T.A.R.T. 

chronic s. d., impairment or altered function of related components of the somatic (body framework) system. It is characterized by tenderness, itching, fibrosis, paresthesias and tissue contraction. Identified by T.A.R.T. See also T.A.R.T. 

linkage, dysfunctional segmental behavior where a single vertebra and an adjacent rib respond to the same regional motion tests with identical asymmetric behaviors (rather than opposing behaviors). This suggests visceral reflex inputs. 

primary s. d., 1. The somatic dysfunction that maintains a total pattern of dysfunction. See also key lesion. 2. The initial or first somatic dysfunction to appear temporally. 

secondary s. d., somatic dysfunction arising either from mechanical or neurophysiologic response subsequent to or as a consequence of other etiologies. 

type I s. d., 1. A group curve of thoracic and/or lumbar vertebrae in which the freedoms of motion are in neutral with side bending and rotation in opposite directions with maximum rotation at the apex (rotation occurs toward the convexity of the curve) based upon the Principles of Fryette. (American usage). 2. Second degree 22 dysfunction based upon the Laws of Lovett (French usage). 

type II s. d., 1. Thoracic or lumbar somatic dysfunction of a single vertebral unit in which the vertebra is significantly flexed or extended with side bending and rotation in the same direction (rotation occurs into the concavity of the curve) based upon the Principles of Fryette (American usage). 2. First degree dysfunction based upon the Laws of Lovett (French usage).

somatogenic: That which is produced by activity, reaction and change originating in the musculoskeletal system. 

Covered Indications

OSTEOPATHIC MANIPULATIVE Treatment is medically necessary when performed by a qualified physician who has examined the patient and determined that there is somatic dysfunction in one or more body regions and documented this in the medical record. 

Limitations:

• OMT procedure codes should be reported based on the number of body regions involved that were treated. The medical record documentation should clearly note the body regions treated, which would justify the procedure code billed. Factors that may affect frequency and duration of treatment are: severity of illness, duration or chronicity of the patient’s condition and the presence of co-morbidities. These factors should be reflected in the medical record if they contribute to the physician’s treatment approach. Body regions referred to are:
• Head region 
• Cervical region 
• Thoracic region 
• Lumbar region 
• Sacral region 
• Pelvic region 
• Lower extremities 
• Upper extremities 
• Rib cage region 
• Abdomen and viscera region
• Only one OMT service should be billed per day, based on the description of the procedure code.
• OSTEOPATHIC MANIPULATIVE Treatment is not covered when the indications of coverage are not met and when the documentation of a somatic dysfunction is not present in the medical record.
• All medical treatment has a goal. If a response is not seen within a reasonable timeframe 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. If there is failure to progress then the treatment needs to be modified.
  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, treatment enters the chronic phase.
  3. Chronic phase OMT involves chronic illness or condition such as chronic pain syndrome with depression, post-polio syndrome and malignant disease, should be as necessary, but not expected to be more than two times per month unless explained in the medical record.
  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 may be appropriate to perform OMT on a patient who is hospitalized if the physician feels it is medically necessary to the patient’s treatment. The medical record should support this treatment decision.

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

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Documentation Requirements

Please refer to the Local Coverage Article: Billing and Coding: OSTEOPATHIC MANIPULATIVE Treatment (A57786) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD.

Utilization Guidelines

Please refer to the Local Coverage Article: Billing and Coding: OSTEOPATHIC MANIPULATIVE Treatment (A57786) for utilization guidelines that apply to the reasonable and necessary provisions outlined in this LCD.

First Coast Service Options, Inc. reference LCD number – L29376

American Osteopathic Association (2006). Position paper on Evaluation and Management services (E/M) with OSTEOPATHIC MANIPULATIVE Treatment (OMT). 

American Osteopathic Association (2002). Glossary of Osteopathic Terminology.

American Osteopathic Association (1998). Protocols for OSTEOPATHIC MANIPULATIVE Treatment (OMT).

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