It has long been the position of the American Osteopathic Association (AOA) that an osteopathic physician should report an E/M service with modifier 25 Significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service appended for OMT, on both initial and follow-up visits, provided that the services are medically necessary and supported by the clinical documentation. The American Medical Association and the American Academy of Osteopathy have affirmed the AOA’s position that an E/M service should be billed at the same visit as OMT.
The CPT® introductory language for the OMT codes specifies that modifier 25 is used to indicate that a separate and identifiable E/M service was provided above the usual pre- and post-service work. An amendment to the CPT® introductory language was added in 1999, clarifying that a separate diagnosis is not required to report both an E/M and OMT on the same date of service.
Payers often believe the E/M service is included as a component of the OMT procedure or that there is an overlap in expenses between the E/M and OMT as justification for payment denial. However, the Relative Value Scale Update Committee (RUC) and Centers for Medicare and Medicaid Services (CMS) have adjusted reimbursement for CPT codes typically reported with E/M codes for any overlapping costs. The RUC specifically discussed the pre and post service physician work associated with OMT CPT codes 98925-98929 and determined the time for the pre and post service physician work is distinct from the separately reportable E/M service reported on the same day as the relevant OMT code. In the 2012 Medicare Physician Fee Schedule Final Rule, CMS refined and finalized the physician time requirements and the associated Relative Value Units (RVUs) for the OMT codes to not include E/M services, confirming the position that the physician work for OMT and E/M are separate and distinct.
Moreover, if evaluating the work RVUs between E/M services and OMT procedures, the RVU values alone indicate there is not an overlap between the work. For example, if comparing CPT codes commonly performed on the same date of service, E/M 99213 with a work RVU of 1.30 to OMT procedure 98926 3-4 regions with a work RVU value of .71, the OMT is -.59 RVUs less than the 99213 E/M. If the 99213 E/M service were included in the 98926 OMT procedure we would expect the OMT work RVU to be greater than the E/M work RVU and it is not. The work RVU values assigned to E/M and OMT codes further confirms the position that there is not an E/M component included in the OMT.
Pay Attention to Coverage Guidelines
The AOA’s physician services team engages with private payers to advocate on behalf of physicians to decrease administrative burden, streamline payment of claims, and improve patient outcomes. They work directly with private payers when coverage policies delay payment or impede patient care.
Some payers, from CMS to United Healthcare, have well-established coverage policies on OMT. Visit Private Payer News to view several that may impact your practice.
CMS local coverage determinations (LCD) article A56954 states that “If a significant, separately identifiable evaluation and management service above and beyond the osteopathic manipulation service is provided, this must be indicated by reporting modifier 25 to the E&M service code. OMT utilized at a follow-up visit is not the same as follow-up OMT. A follow-up visit for OMT is a predetermined service and a follow-up visit where OMT is utilized is not necessarily predetermined unless the preceding progress note denoted it to be an OMT visit.”
Medicare Administrative Contractor NGS states in their coverage guidelines for OMT (LCD ID L33616) that no E/M service is warranted for previously planned follow-up OMT treatments unless a new condition occurs, or the patient’s condition has changed substantially, necessitating an overall reassessment of the treatment plan.
LCD A 55318 provides responses to related to Osteopathic Manipulative Treatment that may be of interest.