Coding for OMT. Rance McClain, DO Assistant Professor Family Medicine KCUMB-COM

Transcription

1 Coding for OMT Rance McClain, DO Assistant Professor Family Medicine KCUMB-COM

2 Learning Objectives n Understand CPT codes for Osteopathic Manipulative Treatment (OMT) n Apply correct coding to a thorough history and physical examination n Utilization of the -25 Modifier to the E&M code n Apply knowledge in case study situations

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4 Five Steps to Correctly Coding for OMT visits 1. Perform and document a thorough history and examination. 2. Determine, perform and document therapeutic and diagnostic intervention. 3. Put Somatic Dysfunction and the OMT Code first on encounter forms "Somatic Dysfunction as noted above" in your dictation. 4. List secondary diagnosis on encounter forms and in dictation. 5. Use the -25 Modifier on the E&M Code.

5 CPT Codes n OMT codes are Current Procedural Terminology (CPT) codes designed to reimburse us for performing manipulative medicine on our patients n Positive outcomes helped to establish OMT within the federal codes and eventually to become recognized in the CPT Manual in 1994 n Prior to this OMT was included in HCPCS

6 HCFA Common Procedural Coding System (HCPCS) n This alpha-numeric classification system is used to report the use of drugs, supplies and durable medical equipment as well as some procedures. n Example: L0180 Cervical, multiple post collar, occipital/mandibular supports, adjustable

7 CPT Codes n CPT Codes for OMT are broken down by numbers of regions and are intended to correlate with the somatic dysfunctions ICD-9-CM codes regarding the specific regions treated n These codes should be used for both inpatient and outpatient treatment

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9 CPT Codes n n In 1992, the entire coding system for evaluation and management (E/M) was changed The new E/M codes range from to and are organized according to site of service; new vs. established patient and the level of care provided n n The appropriate code to report is based on key components: history; examination; medical decision making; counseling; coordination of care; nature of presenting problem; and time The first three components (history, examination and medical decision making) are considered the key components in selecting a level of E/M service.

10 CPT Codes n Outpatient visits: n n New patients n n Established patients n Inpatient visits: n n Depends on services provided, enough info for a lecture in itself

11 n Consults: CPT Consult Codes n outpatient consults ( ) n used when another provider sends someone to be evaluated and treated n confirmatory consults ( ) n These are now gone, no longer used

12 CPT Consult Codes n If you use the consult codes you must send a letter to the referring provider n A cc or photocopy of your note is unacceptable unless you send a letter or fax stating you saw the patient and that your note is en route n This can be a form letter, but even if the referring doctor is within your group practice, a written response from the consultant is still required

13 ICD-9-CM Codes n International Classification of Diseases, 9 th Edition, Clinical Modification n Classification system where diseases, etc are assigned numbers n Somatic Dysfunctions are grouped and divided into 10 subcatagories of one diagnosis

14 ICD-10 n The deadline for the United States to begin using Clinical Modification ICD-10-CM for diagnosis coding and Procedure Coding System ICD-10-PCS for inpatient hospital procedure coding is currently October 1, n The deadline was previously October 1, n All HIPAA "covered entities" must make the change

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16 Who Gets To Use These? n Physicians with training in OMT should make it part of their practice today. n Offers holistic treatment, more satisfying patient encounters and an economic boost to the practice n Commonly asked question n Can MD s do OMT and bill for the service?

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18 Who Gets To Use These? n Training for OMT, like any other procedure, can be part of the allopathic residency and within the unrestricted scope of practice for an MD n The American Osteopathic Association (AOA) defends the right of MDs to practice OMT

19 Who Gets To Use These? n OMT is NOT THERAPY! n OMT is a treatment option by definition and in practice and is reimbursable as such n OMT also is not the same as chiropractic therapy n there are distinct codes for OMT vs. chiropractic manipulative therapy (CMT) n Note too that the AMA CPT coding manual clearly states that code descriptions are in no way intended to be specialty- or profession-limiting n Therefore, an MD or DO can do CMT. A chiropractor can do OMT

20 Modifiers n Modifiers are designed to better describe a code or how that code is being used in conjunction with another code or modifier n Typically it is used for two unrelated problems such as a treating a UTI at the time of an OMT n The economic incentive comes from the CPT guideline that a patient visit and OMT can both be billed at the same visit using modifier 25 n This is not to say that all payors honor the guideline

21 Modifiers n With OMT, the diagnosis somatic dysfunction is listed first with the correlating ICD code(s) and CPT code without a modifier n The second, third, etc. diagnoses are listed and these justify or create medical necessity for the E&M service billed (your consult, in or outpatient codes) n The E&M code gets a modifier here just like the UTI example, but the E&M code need not be for a separate problem and can in fact be what prompted the OMT!

22 Modifiers n CPT 1999 clarification: n the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. n OMT as separate from E&M was further supported in 2004 recommendations

23 Modifiers n The 51 modifier is used to indicate multiple procedures n A patient might come to the office for scheduled procedures such as lesion removals and ask for an osteopathic treatment before the surgical procedures n For instance, the patient is scheduled for excision of benign lesion of the arm but has back pain and requests an OMT service as well: codes could be and

24 Modifiers n The National Correct Coding Initiative (NCCI) edits from CMS bundle injections including lumbar epidurals into the OMT codes n If an injection is a distinct procedural service such as an unrelated joint injection or trigger point injection, a 59 modifier should be appended to the code for the lesser procedure.

25 Don t Get Bundled Up n Bundling definition: n A method by which the insurance company decides to combine payment for two or more medical services n Pennsylvania Academy of Family Physicians General Counsel Charles Artz, Esq. cites the HIPAA Transaction and Code Set standard as the statutory framework requiring payors to honor the CPT codes, code descriptors and modifiers. n He has successfully employed his argument in court.

26 Don t Get Bundled Up n Further evidence against bundling is the minimal relative value unit (RVU) assigned to OMT which sets the Medicare physician fee for the procedure n The work RVU for OMT code is According to the AOA, the OMT codes are valued only for the actual work of the procedure n This is the same work value as code 99212, says AAFP Coding & Compliance Specialist Cindy Hughes, CPC. Obviously when payors say that there is preservice work included in the OMT codes, they are not accounting for much.

27 Don t Get Bundled Up n The AOA suggests physicians negotiate to add the following language into their payor contracts: n n n MCO agrees to adhere to the CPT codes, including notes, guidelines and instructions printed within the codebook and agrees not to bundle payment codes unless the edit conforms to the attached fee schedule and CPT. (Attach a fee schedule for the OMT and E/M codes- use the fees the physician expects to be paid.) In addition, MCO agrees to respect the CPT modifier 25 when used with an office visit and a procedure such as OMT when performed on the same day. (or in the alternative, MCO agrees to pay E/M and OMT as Medicare does. ) Also, MCO warrants that each payor subject to this agreement conform to the fee schedule and these provision.

28 Don t Get Caught Under the Cap n Careful review of managed care contracts will tell physicians whether OMT is capitated with other services n Physicians are encouraged to read the contract themselves or ask a health law attorney to do so as some payors do not properly interpret or communicate the exact nature of the capitation agreement

29 Don t Get Caught Under the Cap n Physicians and their attorneys are encouraged to renegotiate contracts to exclude OMT from capitation or increase the per patient fee over what is being offered physicians who do not perform OMT n If a physician can carve out OMT from capitation, the AOA suggests including a list of OMT codes that will be paid fee for service.

30 You ve Been Denied n Denials of correctly coded OMT visits n It is worth a physician s time and effort to resubmit denials and educate payors on correctly applying CPT codes related to OMT n Be sure to thoroughly document the history, examination and medical decision making (MDM) to support an appropriate E/M code. While all physicians know not to supplement documentation to upcode, neither should they omit information from the history or exam that supplements the diagnosis process.

31 After Further Review n Review the Explanation of Benefits (EOB) provided by the payor. n This will indicate what you billed and how it was recorded by the claims processor. n Sometimes errors are made by the claims processor in entering data, so this could be one reason for rejection. n Make sure you have attached the -25 modifier to the E/M code reported as not doing this will flag the E/M service for nonpayment.

32 After Further Review n Be sure that the patient has met all insurance deductibles and copayments. n Also be sure that osteopathic manipulative treatment is covered under the patient's policy. n A patient's insurance information should be updated each time the physician sees that patient to ensure that the patient has not changed payors or type of coverage.

33 Throw the Red Flag and Appeal n When you are sure that all of the above conditions have been satisfied and you feel that an error has been made in processing, you need to send an appeal letter to the payor. n If possible, you should address your appeal to a specific individual at the payor, such as the carrier medical director or claims manager. The claims processor who processed the original claim will have little or no authority to adjust the claim.

34 Throw the Red Flag and Appeal n The letter should include: n the claim number, which is listed on the EOB n the patient's identification number n the provider (physician) identification number n an explanation from the physician as to why (s)he is appealing this claim n complete documentation should be attached, including a copy of the original claim filed as well as the EOB.

35 Coding Case Study n Subjective: n A 20-year-old African-American male complains of low back pain that began 3 days ago after he lifted a heavy object. Cannot straighten up when walking. Pain with change of position. Denies radiation of pain, it stays along the low back and waist line. Denies areas of numbness. Comfortable when Lying down. Ibuprofen helps some. Has used heat with some help. No prior history of back pain or injury. Currently taking medication for seasonal allergies, of which he has had increased symptoms of late. Remiander of medical/surgical history is unremarkable.

36 Coding Case Study n Objective: n Musculoskeletal Exam n Tenderness noted over lumbar and sacral regions n Inability to extend lumbar spine when standing n Muscle spasms noted in paraspinals of the lumbar region n Decreased range of motion of lumbar spine and sacrum was noted on active and passive motion testing n Neurologic exam normal n Osteopathic exam n L1-5 N RrSl n Bilateral sacral flexion n HEENT exam n Boggy nasal edema with clear drainage

37 Coding Case Study n Assessment: n Somatic dysfunction lumbar, sacral and n Lumbosacral sprain/strain n Allergic Rhinitis due to pollen n Plan: n OMT (appropriate techniques used)*, applied to the lumbar and sacral regions n Continue ibuprofen n No lifting, bending or twisting n Continue Loratidine, add fluticasone nasal spray daily n Follow up in two days to reevaluate patient progress n Coding For This Case n OMT two body regions; lumbar/sacral n Evaluation/management; new patient 99203(-25)

38 Don t Forget to Document n Manipulation Methods n Body Regions, general and specific n Instructions n Sample documentation: n Patient treated in prone and lateral recumbent positions with ST/MFR then HVLA to the lumbar spine and in prone position with ME to the sacrum. Patient was reassessed and resolution of the somatic dysfunctions was confirmed and patient stated their symptoms were much improved.

39 Sources 1. OMT Coding Strategies To Boost Your Bottom Line; Implement these strategies for better OMT reimbursement. Douglas J. Jorgensen, DO, CPC. Osteopathic Family Physician News. Osteopathic Principles and Procedures - April, Consistency Counts for OMT Coding; Osteopathic family physicians need to be both highly skilled in medicine and practice management. Douglas J. Jorgensen, DO, CPC. Osteopathic Family Physician News. April, Osteopathy: OMT Codes AOA Website ( Practice Management section, Billing and coding subsection.