Making Money with OMT

Review of Billing and Coding Office visits with OMT

Presenter: Sarah James, DO

Disclosures

• I have no corporate or pharmaceutical sponsorship

Objectives

• Review general guidelines for documentation, billing and coding for outpatient E/M visits

• Discuss procedural cost for preforming OMT• Review specific scenarios when OMT is utilized

and how to confidently document, bill and code for it

• Practice applying new our refreshed knowledge to actual cases

E/M Service Coding

• Patient type• Setting of service• Level of E/M service performed.

Patient type

• Patient Type– New– Establish

• Setting of Service– Office, other outpatient setting– Hospital inpatient– Emergency Dept– Nursing facility

Level of E/M Service Provided

• Three key components– History

• Chief Complaint• Location, Duration, Quality, Severity, Timing, Context,

Modifying factors, Associated Symptoms• ROS-pertinent, extended, complete• PFSH-Past, Family, and social history

– Physical Exam-focused or detailed– Medical Decision Making-straight forward, minimal

complexity, moderate complexity, High Complexity

Documentation Basics

• For any level for an ESTABLISHED patient you need two out of three levels met

History For Established Patient

Level 3 (99213): needs 2+ components plus 1 ROS no PSFH

Level 4 (99214): needs 4+ components, plus 2 ROS, PLUS one PSFH

Exam for Establish Patient

Level 3 (99213) needs 2+ components

Level 4 (99214) needs 5+ components or one DETAILED exam +2 other systems

Medical Decision Making for Establish Patient

• Level 3 (99213) needs minimal

• Level 4 (99214) needs moderate

The Key is:

DocumentationDocumentation

Documentation

OMT Procedure Documentation

• Step 1) Document physical exam findings and osteopathic findings(somatic dysfunctions) in your note

• You must have documentation of the somatic dysfunctions found in each body region that you are treating.

• There are 10 possible body regions.– Regions are: Head, cervical spine, thoracic spine, lumbar spine,

sacrum, pelvis, upper extremity, lower extremity, ribs, and abdomen/other

– ex) Body Region, Somatic dysfunction C spine: Hypertonic PSM and trapezius bilat:, Pelvis: left innominate restriction:,Lower extremity: Hypertonic quads and psoas bilat

OMT Procedure Documentation• Step 2) Use allopathic diagnosis a your “primary” diagnosis code(s)

– ex) cervicalgia, tension headache, lumbago, sinusitis, and/or hip pain

• Step 3) Then add the regions that you treated (this is correlated directly with the somatic dysfunction documentation in your note)– M99.00 Segmental and somatic dysfunction of head– M99.01 Segmental and somatic dysfunction of cervical region– M99.02 Segmental and somatic dysfunction of thoracic region– M99.03 Segmental and somatic dysfunction of lumbar region– M99.04 Segmental and somatic dysfunction of sacral region– M99.05 Segmental and somatic dysfunction of pelvic region– M99.06 Segmental and somatic dysfunction of upper extremity– M99.07 Segmental and somatic dysfunction of lower extremity– M99.08 Segmental and somatic dysfunction of rib cage– M99.09 Segmental and somatic dysfunction of abdomen and other regions

OMT Billing and Coding

• Step 4) Bill for the appropriate level of service– Most often will be 99213 (level 3) or 99214 (level 4)

• Step 5) Add the appropriate billing code for the number of regions you treated– 98925 1-2 regions $32.42– 98926 3-4 regions $42.95– 98927 5-6 regions $55.82– 98928 7-8 regions $65.09– 98929 9-10 regions $75.12

Can I bill for OV with scheduled OMT?

Yep!Must evaluate the need for OMT and what SD

is now present=should ALWAYS be able to get a Level 3 established patient OV

BUT, often you should use a Level 4 established OV if the problem is acute on chronic or new problem

What does OMT pay?

• 98925 1-2 regions $32.42• 98926 3-4 regions $42.95• 98927 5-6 regions $55.82• 98928 7-8 regions $65.09• 98929 9-10 regions $75.12

How much money are we talkin’?

98925 1-2 body regions= $32.27

Average full time pt/day=18

Treat 3 pts with 98925(plus OV)/day= ~$100

4 days in clinic/week= $400, $1600/month

46 week year=$18,400

Treat 4 pts/day x 5 days/wk x46 wks=$29,440

ICD-10!

• ICD-10-CM/PCS is a replacement for ICD-9-CM diagnosis and procedure codes.

• The implementation of ICD-10-CM/PCS will not impact the use of CPT and alpha-numeric Healthcare Common Procedure Coding System codes.

Case 1-Lets practice

• What level of service is this history?

Case 1

• Level 4– Has at least 4 HPI elements, 2-5 ROS, and 1 PFSH

Case 1

• What Level of service is this exam?

Case 1

• Level 4– Has at least 5 systems

Case 1

• What Level is this decision making?

Case 1

• Moderate—Level 4– Advised on medication use/discontinue, labs for

other possible causes of patient’s symptoms that are not clearly defined

Summary of Case 1

• History-Level 4• Exam-Level 4• Medical Decision making-Moderate=Level 4

• Establish patient: Only need 2 of 3 to achieve level of service Level 4 (99214)

Case 2-History

Case 2-History

• Level 4– Has at least 4 HPI elements, 2-5 ROS, and 1 PFSH

Case 2-Exam

Case 2-Exam

• Level 4– Has at least one detailed exam and 2 others

Case 2- with OMT

Case 2-Decision Making

• Level 3 or 4– Minimal to moderate due to adjustment of Lyrica

OMT Procedure

• Treated 10 of 10 possible body regions

Summary of Case 2

• History- Level 4• Exam- Level 4• Medical Decision Making- Level 3-4– 2 of 3 met=Level 4 (99214)

• PLUS OMT procedure, add -25 modifier– With

Case 3

• S: Nursing notes reviewed. Aleah Harris is a 5 year old female who presents with a 1 day(s) history of left - ear pain. Dull ache. No drainage out of the ear. Associated upper respiratory symptoms: cough, rhinorrhea and fever up to 102.5 for 3 days. Ibuprofen and tylenol alternating daily. Has not had any medicine today. Is behaving normally today. Over the weekend was more lethargic and took a naps which is unusual. Past history of ear problems: episodic past otitis media and last time was in January 2014.

Case 3-History

• Level

Case 3-Exam

BP 100/52[ped's cuff, rt arm[, Pulse 128, Temp 101.8 °F (38.8 °C), Temp Src: Oral, Resp 30, Ht 3' 8.5" (1.13 m), Wt 48 lb (21.773 kg),

Ears: Right: External - normal Canal - nonerythematous TM - nonerythematous, cone of light intact

Left: External - normal Canal - nonerythematous TM - intact erythema, dullness, behind TM purulent fluid

Nose/Sinuses: clear rhinorrhea, edematous turbinates Oropharynx: no erythema or exudate Neck: anterior cervical nodes - bilateralLungs: clear to auscultation

Case 3-Exam

• Level

Case 3-Medical Decision Making

A/P AOM- Ceftin for 10 days. OMT, mother verbally consented

Discussed home care and OTC medications for symptomatic relief.

Recheck as needed for persistent, worsening, or new symptoms

Case 3-Exam

• Level

OMT Documentation

Cranial: Left internally rotated temporal boneCervical: OA-ERrSl, hypertonic PSMSacrum: Bilat sacral flexion

Treatment: Cranial, ME, MFR, and Soft Tissue

Patient tolerated procedure, symptoms improved, and somatic dysfunction improved.

Case 3

What DX do you document?1-AOM (primary)2-Nonallopathic somatic dysfunction of Head3-Nonallopathic somatic dysfunction of Cervical4-Nonallopathic somatic dysfunction of Sacrum

How do I add OMT to Office Visit?

• Bill for your level 3, 4, or 5 OV, PLUS regions treated with -25 modifier.

Case 3-Summary

• History• Exam• Medical Decision Making• OMT

Case 4-History

Case 4-Exam

Case 4- Medical Decision Making

Questions?

• Hope this was helpful

References

• Waller, T MD;Level II vs Level III Visits: Cracking the Codes.Fam Pract Manag. 2007 Jan;14(1):21-25.

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

• http://www.thenationalcouncil.org/wp-content/uploads/2013/01/ICD-10MythsandFacts.pdf