How to bill for osteopathic manipulative treatment and E/M in a single visit

Every time physicians assess a patient for osteopathic manipulative treatment (OMT), they must perform an examination, identifying the patient’s problems and then performing the OMT to manage them.

Unlike some procedures, the patient's response to OMT can be assessed immediately and the physician can note if there is improvement, without the need for a follow-up visit. Therefore, it is possible to bill an evaluation and management (E/M) code plus an OMT procedure code with nearly every visit that includes OMT. Here’s how to code and document such visits properly:

Remember the new E/M coding rules. Physicians and other qualified health professionals can now bill for E/M services based solely on either the total time spent on the visit or the level of medical decision making (MDM). But remember, if you choose to code the E/M portion of the visit based on time, you cannot include the time you spend on separately billed procedures, including OMT. This is not an issue when coding based on MDM.

Use modifier 25. When you bill for an E/M service on the same date as a procedure such as OMT, you must include modifier 25. For example, let’s say an established patient presents with acute neck pain. Upon examination, you determine the pain is due to muscular hypertonicity, and you perform OMT on two body regions to address it. If coding based on MDM, you would use code 99213 for the E/M service (one acute, uncomplicated injury with low risk), append modifier 25, and then add code 98925 (OMT of 1-2 body regions).

Consider using modifier 59. On some occasions you may need to use modifier 59 in addition to modifier 25. Modifier 59 comes into play when services and procedures are not typically performed together but are appropriate under that visit’s clinical circumstances (e.g., an E/M service, an OMT procedure, and an IV infusion, all at the same visit). Different payers have different policies on modifier 59, so you may want to check with your payers.

Include somatic dysfunction of the OMT body regions. Your documentation must support the level of E/M service coded and outline the somatic dysfunction that you observed in the body regions you treated with OMT. For example:

Patient is established with family medicine. Patient complains of acute on chronic low back pain for the past two days and describes sacroiliac (SI) joint pain as achy when sitting but sharp when changing positions.

OMT was performed for the low back pain and SI joint pain. Will refer to physical therapy to strengthen pelvic ring. Increase pregabalin to 75 mg for better myofascial pain control.

Include an osteopathic procedure note. When you bill separately for OMT, your documentation must also contain an osteopathic procedure note with a list of the dysfunctional regions, the treatment techniques you used, and the patient’s response to the treatment. For example:

Somatic dysfunction of body region: cervical spine — hypertonic posterior cervical muscles, C4-C5 NRrSr; thoracic spine — thoracic inlet NRrSl, T3-T4 NRrSl; lumbar spine — hypertonic paraspinal muscles.

Techniques: soft tissue, myofascial release, and facilitated positional release (FPR).

Response: Patient's symptoms improved; somatic dysfunctions improved.

Follow-up: as needed.

See the full FPM article: “Demystifying Documentation and Billing for Osteopathic Manipulative Treatment.”