Quick, Effective, and Profitable OMT Sam Byron, DO and Nicklaus Hess, DO 10 February 2017 1700-1830

THE NUMBERS

NEW pts CPT CODE (9920-) wRVU NON-FACILITY ($) FACILITY 1 0.48 41.97   1 0.48 41.97 26.19 2 0.93 71.97 49.62 3 1.42 104.49 75.90 4 2.43 160.23 128.35 5 3.17 201.38 166.87 Updated quarterly Facility—any hospital-owned (any place that bills medicare part A) Non-facility—own your own facility cms.gov/apps/physician-fee-schedule for OH 2016

Established pts CPT CODE (9921-) wRVU NON-FACILITY ($) FACILITY 1 0.18   1 0.18 18.96 9.10 2 0.48 41.62 24.85 3 0.97 70.42 50.37 4 1.5 103.93 77.31 5 2.11 140.37 109.48 Updated quarterly Facility—any hospital-owned (any place that bills medicare part A) Non-facility—own your own facility cms.gov/apps/physician-fee-schedule for OH 2016

wRVUs MGMA DataDive Provider Compensation Mean: 4,991 75th %: 5,828 90th %: 7,069 AMGA’s “2016 Medical Group Compensation and Productivity Survey”* 4,908 Median compensation: $234,706 Family Practice; outpt only American Medical Group Association *Becker Hospital Review

OMT CPT CODE (989-) REGIONS wRVU NON-FACILITY ($) FACILITY 25 1 - 2   25 1 - 2 0.46 30.68 23.45 26 3 - 4 0.71 44.59 35.72 27 5 - 6 0.96 57.84 47.00 28 7 - 8 1.21 71.09 59.26 29 9 - 10 1.46 85.00 71.20 3 regions on 3 pts /wk= added 102.24 wRVUs and $5,143.68. 9min work/wk cms.gov/apps/physician-fee-schedule for OH 2016

Billing: ICD-10 Codes Always include an allopathic ICD-10 code followed by osteopathic ICD-10 codes representing the regions treated: M99.00 – Somatic Dyfunction Head M99.01 – Cervical M99.02 – Thoracic M99.03 – Lumbar M99.04 – Sacrum M99.05 – Pelvis M99.06 – Lower Extremity M99.07 – Upper Extremity M99.08 – Ribs M99.09 – Abdomen/Other

Billing: ICD-10 Codes Always include an allopathic ICD-10 code followed by osteopathic ICD-10 codes representing the regions treated: For Example: “99214-25, 98926. J01.00, M99.00, M99.01, M99.09” Denoting: est pt visit w Acute Maxillary Sinusitis w -25 modifier and 3 region OMT SD of Head/Cervical/Other (lymphatics)

Don’t they know it has nothing to do with The Money?

Tenets of Osteopathy The body is a unit; the person is a unit of body, mind, and spirit. The body is capable of self-regulation, self-healing, and health maintenance. Structure and function are reciprocally interrelated. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function. http://www.osteopathic.org/inside-aoa/about/leadership/Pages/tenets-of-osteopathic-medicine.aspx

W Janig, The Integrative Action of the Autonomic Nervous System; Cambridge University Press, 2006

Rogers FJ, D'alonzo GE, Glover JC, et al Rogers FJ, D'alonzo GE, Glover JC, et al. Proposed tenets of osteopathic medicine and principles for patient care. J Am Osteopath Assoc. 2002;102(2):63-5.

Hruby R. Somatic Dysfunction: A Principled Approach to Diagnosis and the Selection of OMT Modalities. The AAO Journal. 2016;26(1): 7-16.

How is Somatic Dysfunction Affecting the Patient’s Health?

Keys to Successful Patient interaction “Find it, fix it, and leave it alone.” “You treat what you find.” “If you talk with your patients long enough, they will tell you what is wrong with them.” Noll DR, Sthole HJ, Cavalieri TA. Axioms, osteopathic culture, and a perspective from geriatric medicine. J Am Osteopath Assoc. 2013;113(12):908-15.

“Three Techniques, Three Areas, Three Minutes…” “The formula of one sympathetic, one parasympathetic and one lymphatic is a quick and easy way of thinking about how we can do the most for a patient in a minimal amount of time.” Karen Steele, D.O. Bouley J. OMT Benefits Acutely Ill. The DO. November 1994: 54-7.

Common Compensatory Patterns Common compensatory patterns were investigated by J. Gordon Zink, D.O. Four compensatory curves exist Occipitoatlantal junction Cervicothoracic junction Thoracolumbar junction Lumbosacral junction In 80% of healthy people, the pattern of OA rotated left, CT rotated right, TL rotated left, and LS rotated right can be appreciated. The remaining 20% have the opposite pattern. The alternative pattern is necessary for normal lymphatic flow. Trauma and stress can lead to disruption of fascial patterns. Modie R, Shah N. COMLEX Review: Clinical Anatomy and Osteopathic Manipulative Medicine. Baltimore, MD: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2006: 13.

To Find the Dysfunction, You Have to THINK Like the Dysfunction Pocket OMT Manual, 2nd ed; L Grentz; Mountain Medicine Publishing; 2004

Pelvic Diaphragm Release Decreases lymphatic congestion in the pelvis. Find ILAs with index and middle fingers or thumb. Hook digit(s) medially to appreciate resistance representative of the pelvic diaphragm. Can use respiration as activating force or have patient cough ~3x to balance diaphragm. Advance finger(s) cephalad with exhalation until a balance in the tissue is reached. Treat both sides. Ward RC, ed. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2002: 106 Speece CA, Crow WT, Simmons SL. Ligamentous Articular Strain Osteopathic Manipulative Techniques for the Body. Seattle, WA: Eastland Press Incorporated; 2009: 172.

LAR Cross-Hand Sacral Release Speece CA, Crow WT, Simmons SL. Ligamentous Articular Strain Osteopathic Manipulative Techniques for the Body. Seattle, WA: Eastland Press Incorporated; 2009: 76.

LAR Pelvic Torsion Technique Speece CA, Crow WT, Simmons SL. Ligamentous Articular Strain Osteopathic Manipulative Techniques for the Body. Seattle, WA: Eastland Press Incorporated; 2009: 78.

Bilateral Sacroiliac Joint with Forearm Pressure Place palm under the sacrum. Place forearm and hand over the anterior superior iliac spines. Monitor for ease-bind asymmetry. Indirectly or directly meet the ease-bind barrier. Deep inhalation or other release enhancing mechanisms can be helpful. Nicholas AS and Nicholas EA. Atlas of Osteopathic Techniques Second Edition. Philadelphia, PA:Lippincott Williams & Wilkins, a Wolters Kluwer business; 2012: 3769, 3771.

Doming of the Diaphragm Diaphragmatic treatment moves lymph and venous blood from the abdomen and thorax back into circulation. Grasp the lower aspects of the patient’s rib cage with your fingers spread. Direct Test for fascial restriction in all planes of motion (F/E, R, SB). Gather fascia and take up slack. Apply a steady force until tissues are balanced and tension is resolved. Indirect Test for fascial restriction in all planes of motion (F/E, R, SB) Move tissue in the direction of ease or balanced tension until tissue releases. Consider using the patient’s respiration to gently exaggerate diaphragmatic motion. Channell MK, Mason DC. The 5-Minute Osteopathic Manipulative Medicine Consult. Baltimore, MD: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2009: 189.

Rib Raising Contact rib angles with finger pads. Engage soft tissue with a gentle anterolateral force facilitated by downward pressure through the elbows on the table, creating a fulcrum to produce a ventral lever action at the wrists and hands. Draw fingers to provide a lateral stretch. Use torso as a fulcrum. Treat both sides. Reassess. Nelson KE, ed. Somatic Dysfunction in Osteopathic Family Medicine Second Edition. Baltimore, MD: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2015: 69.

Sternum LAR Nicholas AS and Nicholas EA. Atlas of Osteopathic Techniques Second Edition. Philadelphia, PA:Lippincott Williams & Wilkins, a Wolters Kluwer business; 2012: 3909. Speece CA, Crow WT, Simmons SL. Ligamentous Articular Strain Osteopathic Manipulative Techniques for the Body. Seattle, WA: Eastland Press Incorporated; 2009: 148.

Thoracic Inlet Release Introduce left/right translation, rotation or twisting and superior or inferior translation to evaluate available motion for myofascial restrictions. Treat directly or indirectly by holding the position and waiting for a release, the perception of relaxation of tension, to occur. Reassess. Nelson KE, ed. Somatic Dysfunction in Osteopathic Family Medicine Second Edition. Baltimore, MD: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2015: 305. Nicholas AS and Nicholas EA. Atlas of Osteopathic Techniques Second Edition. Philadelphia, PA:Lippincott Williams & Wilkins, a Wolters Kluwer business; 2012: 3653.

Ligamentous Articular Release Speece CA, Crow WT, Simmons SL. Ligamentous Articular Strain Osteopathic Manipulative Techniques for the Body. Seattle, WA: Eastland Press Incorporated; 2009: 109, 110.

Suboccipital Release With the patient lying supine, sit at the head of the table and place your fingertips at the base of the occiput. While suspending the occiput on your fingers, apply cephalad traction. Allow gravity to release suboccipital tension so that the patient’s head falls into your palms. Consider altering the direction of the applied pressure against particularly restricted areas. Nelson KE, ed. Somatic Dysfunction in Osteopathic Family Medicine Second Edition. Baltimore, MD: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2015: 270.

OA Release Place the middle finger of the right hand on the midline of the occiput near the foramen magnum. Have patient tuck chin toward chest. You will feel the posterior tubercle come in contact with your fingertip. Maintain contact with the tubercle until you feel a softening of the tissues and a release of the compression. The finger will move slightly anteriorly as the occipital condyles release back posteriorly.

Resources for when you leave

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2013 copyright from AOA 3rd ed to be released Mar 2017 http://c.ymcdn.com/sites/www.domoa.org/resource/resmgr/imported/AOA%20OMT%20Manual%202013.pdf Verbal permission to use 3rd ed to be released Mar 2017 contact AOA

Douglas J Jorgensen, DO, CPC ACOFP acofp.org Douglas J Jorgensen, DO, CPC “OMT Coding Strategies to Boost Your Bottom Line, Implement these strategies for better OMT reimbursement” “Consistency Counts for OMT Coding, Osteopathic family physicians need to be both highly skilled in medicine and practice management”

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