OMT Billing & Coding

1. OMT Billing & Coding Rocco F. Caveng,Jr., D.O., M.B.A UMDNJ-SOM Spring 2007 *adapted from David Mason, DO

2. OMT - Putting it together Objective/learning points • Using OMT in practice (in/outpatient) • Focused examination • Appropriate level of documentation • Billing/coding 101 (intro for Dr. Student) • Reimbursement for OMT (worth your time?) • Practice makes you efficient & busy

3. Barriers to use OMT • Office not set up right • Inpatient hospital beds • Time constraints • Extra documentation • How to bill/code for this? Educate billing • Out of practice (limited experience in residency) or not seeing it in practice

4. Barrier - solutions • Set up the office with OMT tables • Educate your office staff • Practice makes you efficient (& your staff) • Keep it focused (just like with medical problems) • Keep documentation pertinent, use abbrev. • Know the coding, educate billing dept. • Market yourself • Seek the training in residency/OMM consults • Can make return visit just for OMT (more time)

5. Initial Visit • New or established patients, you should mention your osteopathic skills • Explain that you are a D.O. and what that means. Quick intro to OMT. • Depending on your time constraint OMT now or later • Explain what you are doing to the patient • Keep exam focused, expand as needed

6. Osteopathic Confidence • Use what you know, explain biomechanics to the patient • Don’t let them talk you into unnecessary testing • Trial of OMT first (if appropriate) • They will appreciate it

7. Focused Exam • Sometimes hard to do. Takes practice • Here for HA. Stick with Cerv/thoracic • Low back pain. Lumb/Pelvis/Sacrum • Neck pain: cervical • Medical ex.) 81 y.o. DM, HTN, HLP, COPD, CAD, URI, CKD, BPH, OA, BPV, LBP, SDAT • Lets discuss DM, HTN, Lipids, URI today • Don’t get bogged down in fine details with diagnosis of somatic dysfunction

8. Documentation • If you bill for it, you need to examine it and document what you found • You are already familiar with terms • No different in the office or hospital • Keep documentation pertinent • Examples at the end

9. Billing & Coding Evaluation & Management (E/M) • Superbill • Paper that documents what to bill insurance company for and which diagnosis/procedures • The Three Key components of an E/M service code • History • Examination • Medical decision making

10. Codes to Know (of) • E/M code • 99213, established patient, low complex visit • ICD-9 code (or diagnosis code) • Low back Pain (724.5) • Somatic Dysfunction Lumbar (739.3) • Procedure codes • 98925, OMT 1-2 body regions • 11100, skin biopsy • Testing codes/Lab codes • 93000, EKG ; 87081 Rapid strep ; • Medication administration • Tetanus booster 90718, etc

11. SUPERBILL

12. Current Procedural Terminology • E&M Codes CPT Book • Office Visit Codes NEW Established • 99201 -99211 (nurse) • 99202 -99212 (nurse or EZ) • 99203 -99213 (low complex) • 99204 -99214 (mod complex) • 99205 -99215 (high complex)

13. Hospital New 99221 99222 99223 Hospital Subsequent 99231 99232 99233 Nursing Home 99311 99312 99313 Outpatient Consult New or re-consult 99241 99242 99243 99244 99245 CPT

14. Inpatient new consult 99251 99252 99253 99254 99255 Inpatient re-consult 99261 99262 99263 99264 99265 CPT

15. Then ICD-9 for Dx ‘International Classification of Diseases’ More codes to communicate which diagnoses were managed • HTN (401.1) • Hyperlipidemia (272.4) • Lumbosacral Strain (846.0) • Somatic Dysfunction Cervical (739.1)

16. ICD-9 Codes ICD-9 Codes for ‘Somatic Dysfunction’ (a.k.a. ‘non-allopathic lesion’) these codes are used as your diagnosis code • 739.0 Head/Cranial Somatic Dysfunction (SD) • 739.1 Cervical SD • 739.2 Thoracic SD • 739.3 Lumbar SD • 739.4 Sacral SD • 739.5 Innominate (Pelvis) SD • 739.6 Lower Extremity SD • 739.7 Upper Extremity SD • 739.8 Rib SD • 739.9 Abdominal/Visceral SD

17. OMT Codes (Procedure) • 1-2 areas treated 98925 • 3-4 areas 98926 • 5-6 areas 98927 • 7-8 areas 98928 • 9-10 areas 98929 • 10 areas are Cranial, Cervical,Thoracic, Lumbar, Sacral, Innominate, Upper Extremity, Lower Extremity,Rib cage, Visceral.

18. Modifiers • -25 modifier: ‘separate identifiable’ service on same day (Patient seen for “Headache” diagnosis muscle tension type HA, Cervical Somatic Dysfunction E&M 99213-25mod 98925 ICD-9 codes 307.81 739.1) • For now: important for discussion of OMT billing. Just know if you perform Osteopathic evaluation and OMT then add a -25 modifier • There can be exceptions when you might not use this, some will say use every time, others sometimes, some never

19. Putting it together: Coding • Office visit. Patient seen and evaluated, OMT performed for low back pain • E/M: 99213 (est patient, low complex) • Diagnosis: LBP (724.5), Som Dys (739.3) • Procedures: OMT 1 region 98925 • Add -25 modifier so  99213 -25mod

20. SUPERBILL x1 -25 mod Low back pain (724.5) Somatic Dysfunction Lumbar (739.3)

21. How Often? • Acute vs Chronic. • Weekly? • Monthly?

22. AOA Protocols for OMT • Osteopathic Physicians utilize all recognized medical procedures and available technologies to provide comprehensive health care to patients. • Describe physical findings in objective portion of chart and correspondence.

23. Protocols Continued • As in all medicine a specific diagnosis must first be made. • Usually not appropriate to form a “treatment plan” for OMT. • The choice of OMT techniques is based on multiple factors.

24. Protocols Continued • The three components of an E/M: History, exam, Medical decision making are essential prior to each OMT treatment. • 1. What needs to be treated, • 2. What OMT techniques to use, • 3. Should OMT be augmented by other medical services/procedures?

25. Protocols Continued • OMT should be performed at the appropriate effective frequency as determined through ongoing Medical evaluation and management. • OMT should be performed for the minimum appropriate duration.

26. Protocols Continued

27. Reimbursement for OMT What is the deal? Does OMT pay? • Yes, in multiple ways • Aside from insurance reimburse, you get happy patients, healthier patients, referrals from patients • But you also get paid MORE for visit then if OMT not performed (averaged)

28. OMT Reimbursement • 2 year study (300+ patients) • Overall, average reimbursement for treatment of ‘1-2 body regions’ (98925) is $33.49 when billed only for OMT (separate procedure visit). Average reimbursement for 98925 at same time of office visit (99213-25mod) is $75.86. This is a difference of $42.37 per patient Medicare allowable for OMT (98925) $30.45 Medicare allowable for OMT (98926) $41.98 Medicare allowable for estab. visit (99213) $53.64

29. “You Don’t Get Paid By HMO’s for OMT” • Yes you do! • Quality care points for procedures performed in your office. • Referrals from satisfied patients. • Decreased “over-utilization” • Patients get better, you see them less.

30. -Musculoskeletal Pain -Post Operation prevention and treatment of ileus and atalectasis -Edema -CHF -Pneumonia -Asthma -COPD -Nausea -Diarrhea -Constipation -Obstetrics -Gait disorders -Rheumatologic conditions. others Hospital OMT

31. Case 1 New Patient Subjective A 30 year old male complains of low back pain. It started 2 days ago when lifting some heavy furniture. The patient reports having a sharp pain in his left lower back at the time of lifting. The next morning he was unable to stand straight due to significant pain in low back. Denies numbness/tingling or weakness of lower extremities. He took ibuprofen with mild relief of pain. He has no prior history of back pain/injury. Denies and medical or surgical history. No Allergies to medications. Objective Vitals BP-130/80, P-72, R-18, Temp 98.8 Ext: no edema. Dec ROM Lower Ext due to pain in lower back. Neuro: DTR's +2/4 = b/L, Strength +5/5 = b/L, sensation intact. CN II-XII grossly intact Osteopathic Exam - focused L5 Flexed, Rotated Left, Sidebent Left Lumbar paraspinal muscle spasm, tenderness to palpation L>R Lumbar ROM: FB 75, BB 10, SBL 30, SBR 20

32. Case 1 Assessment 1. Lumbosacral sprain (ICD 846.0) 2. Lumbar Somatic Dysfunction (ICD 739.3) Plan 1. OMT, Myofascial, HVLA to Lumbar spine with improvement of pain and range of motion. 2. Continue ibuprofen as needed for pain 3. Exercise and stretching instruction given 4. Follow up in 1 week E/M: 99202 -25 mod OMT x1 region 98925

33. Case 2 Established Patient Subjective 35 year old male presents to your office for an OMT treatment of his neck pain of 5 years. Reports sometimes starts to get a headache from the tension in the back of his neck. (his history is a car accident 5 years ago with negative imaging results). Mild improvement with Aleve. Occasional stretches and heating pad help. Denies numbness/tingling/weakness of upper extremities. No recent trauma. Objective Vitals BP-120/75, P-68, R-18, Temp 97.8 Physical Exam - focused HEENT/neck: NC/AT, pharynx - benign, Neck supple, No nodes Neuro: DTR's +2/4 = b/L, Strength +5/5 = b/L, CN II-XII grossly intact Osteopathic Exam: C3-5 Extended, Rotated Left, Sidebent Left Tenderness over articular pillars L>R Cervical ROM: FB 70, BB 50, SBL 45, SBR 30, Rot L 80, Rot R 65

34. Case 2 Assessment 1. Cervical Strain (ICD 847.0) 2. Cervical Somatic Dysfunction (ICD 739.1) Plan 1. OMT, myofascial, HVLA to cervical spine with improvement of pain and ROM 2. Continue Naprosyn 500mg PRN for pain 3. Stretching exercises given 4. Follow up 1-2 weeks E/M: 99213 -25 mod OMT x1 region 98925

35. OMT in practice • Use OMT in your practice. • Get the experience now and during residency, seek and you shall find. • If you choose not to use OMT or you use OMT infrequently, know when to refer patients who will benefit from OMT.

36. Summary • Use OMT to improve patient satisfaction. • Become comfortable using OMT and billing and coding for OMT. • Get reimbursed for what you do.