Neurology & Pain Management Coding Alert

Append modifier 25 only in cases where necessary.

Billing for osteopathic manipulation can throw you a challenge if you are not sure what treatment was offered, which part of the body is involved, or if an E/M was done. Advice from our experts will help you to carefully analyze the practical situation and report appropriately.

Find the Correct Code Family

Your osteopathic physicians (DOs, or osteopaths) are fully licensed physicians who operate under the same licensing and certification rules as medical doctors (MDs). You hence, adopt a traditional approach to handle most of their billing matters.

Your DOs may also perform osteopathic manipulative treatment (OMT), for which you may turn to codes 98925 (Osteopathic manipulative treatment [OMT]; 1-2 body regions involved)--98929 (Osteopathic manipulative treatment [OMT]; 9-10 body regions involved). You may have trouble distinguishing between OMT and chiropractic manipulative treatment (CMT), 98940 (Chiropractic manipulative treatment [CMT]; spinal, 1-2 regions)--98943 (Chiropractic manipulative treatment [CMT]; extraspinal, 1 or more regions) or manual therapy techniques, 97140 (Manual therapy techniques [eg, mobilization/manipulation, manual lymphatic drainage, manual traction], 1 or more regions, each 15 minutes).

Tip: "CPT® identifies the following ten separate body regions for OMT: head, cervical, thoracic, lumbar, sacral, rib cage, abdomen and viscera, pelvic, upper extremities and lower extremities," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

If you are billing for osteopathic services, you should remember to treat OMT as any other procedure or modality: If it's performed with a separately identifiable and significant E/M service, 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components...)--99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components...), you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Distinguish OMT From CMT

One common mistake that coders who are new to DO claims make is when they confuse the OMT codes with the CMT series. But CPT® clearly states that OMT services are to be performed by physicians, noting, "OMT is a form of manual treatment applied by a physician to eliminate or alleviate somatic dysfunction and related disorders."

Look at who performed the manipulation: Fully licensed physicians who perform manipulation techniques should report their services using OMT codes. Chiropractors who perform manipulative treatment can bill the CMT codes, and therapists usually bill 97140 for manual therapy techniques. Keep in mind that individual states have their own licensure requirements for which practitioners may perform manipulation. What qualifies an MD to perform manipulative treatment is a matter of state licensure, and some states have stricter requirements than others.

Remember! OMT Does Not Include the E/M Service

Another misconception regarding OMT billing is that E/M services are included in the OMT. In reality, however, a separately identifiable E/M can be reported under CCI rules, as long as the documentation reflects the separate nature and a modifier is used. Practices that aren't billing for the OMT and the E/M separately may be losing out on reimbursement owed to them.

CPT®'s introductory notes before the OMT codes states, "The E/M service may be caused or prompted by the same symptoms or condition for which the OMT service was provided. As such, different diagnoses are not required for the reporting of the OMT and E/M service on the same date."

"The new and established patient visit E/M services are bundled by Medicare NCCI edits into the OMT services. These bundling edits can be bypassed with modifier 25 if the documentation supports that the E/M service was above and beyond the usual preservice and postservice work associated with OMT," says Hammer.

You Can Report For Same-day OMT and E/M

Suppose an established patient presents to the physician complaining of a new case of lateral epicondylitis (726.32) and the DO performs a level-three E/M visit to evaluate the problem, followed by an OMT of the patient's left arm. He should code the visit using 99213-25 for the E/M and 98925 for the OMT.

Case in point: Last spring, a DO in Connecticut had to repay $379,764 after improperly billing E/M services on 95 percent of his OMT claims. When the government reviewed the doctor's records, auditors concluded that he often had "no documentation of a significant, separately identifiable reason for the patient's visit (i.e., the patient was there only for regularly scheduled OMT services)," and in fact most records lacked documentation of any E/M service being performed at all.

Watch Your Units

Coders should note that different OMT codes exist for billing between one and ten body regions. Therefore, if the physician's chart reads, "OMT to lumbar, sacral, leg and pelvic regions," the coder should not record the visit as 98925 with four units of service. Instead, the practice would report 98926 with one unit of service, which covers OMT for three to four body regions. Likewise, coding is not based on the number of lesions within a single region. For example, if three lesions are treated in the cervical region, this would be reported as 98925 with one unit of service, as the CPT® code descriptor indicates 1 to 2 body regions involved.

Don't abuse it: OMT is not performed at every visit to a DO. If a patient presents to the DO because she's recovering from a stroke, the DO might just perform an E/M and determine the patient's status, checking for improvements and ensuring that the current plan of care is working, but he may not perform an OMT.

Likewise, some patients may not need an E/M service at every visit. You can bill an OMT alone, without an E/M visit. It should be billed as any other procedure would be.