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 Setting of Service New Establish 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: 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

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 - bilateral Lungs: 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 bone Cervical: OA-ERrSl, hypertonic PSM Sacrum: 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 Head 3-Nonallopathic somatic dysfunction of Cervical 4-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