Making Money with OMT Review of Billing and

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: 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) – – – – – M 99. 00 Segmental and somatic dysfunction of head M 99. 01 Segmental and somatic dysfunction of cervical region M 99. 02 Segmental and somatic dysfunction of thoracic region M 99. 03 Segmental and somatic dysfunction of lumbar region M 99. 04 Segmental and somatic dysfunction of sacral region M 99. 05 Segmental and somatic dysfunction of pelvic region M 99. 06 Segmental and somatic dysfunction of upper extremity M 99. 07 Segmental and somatic dysfunction of lower extremity M 99. 08 Segmental and somatic dysfunction of rib cage M 99. 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! Ø Must evaluate the need for OMT and what SD is now present=should ALWAYS be able to get a Level 3 established patient OV Ø 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’? Ø 98925 1 -2 body regions= $32. 27 Ø Average full time pt/day=18 Ø Treat 3 pts with 98925(plus OV)/day= ~$100 Ø 4 days in clinic/week= $400, $1600/month Ø 46 week year=$18, 400 Ø Treat 4 pts/day x 5 days/wk x 46 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-ERr. Sl, 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): 2125. • https: //www. cms. gov/Outreach-and. Education/Medicare-Learning-Network. MLN/MLNProducts/downloads/eval_mgmt_serv _guide-ICN 006764. pdf • http: //www. thenationalcouncil. org/wpcontent/uploads/2013/01/ICD 10 Mythsand. Facts. pdf