Billing and Coding Corner
The MOA Payor/Payee Committee works to assist members who report concerns with the OMM reimbursement policies of various insurers/payors. We work to provide osteopathic physicians with an understanding of how to be reimbursed for OMT services and serve as a resource to members who encounter difficulties with OMT reimbursement. It is very important that you fill out a Hassle Factor Complaint form and alert the MOA if you experience reimbursment issues.
AOA Position on E/M and OMM Services
The position of the AOA is that an osteopathic physician should report E/M services with OMM on initial office visits as well as on follow-up visits, if the services are medically necessary and are supported with appropriate documentation according to the E/M documentation Guidelines.
The modifier -25 must be used with the E/M service to indicate that the E/M service is a separately, identifiable service from the OMM service. A separate diagnosis is not required for each of the services. The same diagnosis may be reported.
The term “significant, separately identifiable E/M service” is not defined either in Current Procedural Terminology (CPT) or in Medicare guidelines. The AOA’s position is that “significant, separately identifiable” means that the physician has documented medically necessary care to the level specified in the E/M documentation guidelines.
Furthermore, osteopathic physicians as fully licensed medical providers are legally obligated for the total care of the patient. As such, they must document and provide an evaluation of that patient throughout their course of treatment.
Rational for the AOA Position
M Codes for OMM were adopted by HCFA in 1982. These codes did NOT include E/M services, which were considered to be separately reportable.
In establishing the Medicare Resource Based Relative Value Scale (RBRVS) fee schedule, the Hsiao (Harvard) Study separated the work of OMM from osteopathic E/M by having two separate survey forms with separate vignettes. It was never the intent of Hsiao or the osteopathic physicians involved in the creation of the survey to bundle E/M with the work of OMM.
The CPT introductory language to the OMM codes indicate that the modifier -25 is to be used to indicate that the E/M service provided is a “significant, separately identifiable E/M service, above and beyond the usual preservice and postservice work associated with the procedure.”
In 1999, an amendment to the CPT introductory language to the OMM codes clarified that a separate diagnosis is not required to report both as E/M and an OMM service on the same day.
The physician work Relative Value Units (RVUs) for the OMM codes were derived from the original Hsiao Study on the HCPCS codes that were used to report OMM services at the time the Hsiao Study was conducted. The osteopathic physicians who participated in the Hsiao Study were given instructions that clearly separated OMM from E/M services. These work RVUs were then “crosswalked” to CPT when the OMM cods were first included in CPT 1994.
The physician work RVUs assigned for the OMM codes reflect that separation. As an example, the lowest level of E/M service for an established patient which requires actual face to face contact between physician and patient is CPT Code 99212 which has a work RVU of 0.45. The work RVU for OMM to 1-2 body regions (CPT Code 98925) is also 0.45. Thus, the work of the E/M service CANNOT be considered to be included as the work value for the OMM procedure.
Osteopathic Manipulative Treatment (As stated in the 2001 CPT codebook)
Osteopathic manipulative treatment is a form of manual treatment applied by a physician to eliminate or alleviate somatic dysfunction and related disorders. This treatment may be accomplished by a variety of techniques.
Evaluation and Management services may be reported separately if, using the modifier “-25,” the patient’s condition requires a significant, separately identifiable E/M service, above and beyond the usual preservice and postservice work associated with the procedure. The E/M service may be caused or prompted by the same symptoms or condition for which the OMM service was provided. As such, different diagnoses are not required for the reporting of the OMM and E/M service on the same date.
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.
- 98925 Osteopathic manipulative treatment (OMM); one to two body regions involved
- 98926 three to four body regions involved
- 98927 five to six body regions involved
- 98928 seven to eight body regions involved
- 98929 nine to ten body regions involved
What to do if you’re not getting paid for OMM
Despite the clarity of the AOA and the CPT codebook, regarding charging for OMM and the office visit on the same date of visit, some insurance companies still will not pay for both services. In the insurance companies explanation of benefits (EOB) the reasoning goes something like this; THIS PROCEDURE IS NORMALLY INCLUDED IN THE COST OF THE PRIMARY PROCEDURE. If the claim is not submitted using a modifier 25 than the insurance company probably will not pay. A modifier 25 is necessary regardless of the insurance company for reporting of the OMM and E/M service on the same date.
If you are using the modifier 25 and your documentation is appropriate for the office visit and your still not getting paid for both may we suggest you, your clinical director or office manager write a letter to the specific insurance company citing the facts stated above and requesting they respond appropriately. Included are template letters that you are welcome to duplicate and use if you would like.
On occasion an insurance company will deny payment with the reasoning that looks something like this; CHARGE EXCEEDS CONTRACTED RATE. Look at the service code that they used; often times it is a physical therapy (PT) service. In other words, the insurance company’s computer sees our OMM 98925-98929 codes as a PT service. If this is the case, the insurance company needs to be informed that their information is inaccurate and that our 98925-98929 codes are “medical service codes” not “PT service codes.” The last template letter included may be of some use in helping the insurance carrier understand that you are a physician and deserve to get paid.
