Documentation and Billing for OMM

00:01 Documentation and Billing for osteopathic Manipulative Medicine.

00:05 So it's vital to know the proper steps to correctly documenting and coding for OMT in order to get proper reimbursement.

00:13 So first and foremost, perform and document a thorough history and examination on your patient.

00:19 Determine and perform and document therapeutic and diagnostic OMT if indicated.

00:25 List your primary diagnosis in the assessment that is not a somatic dysfunction.

00:31 So put down what your patient came in for, complaining of and your diagnosis.

00:36 Then list the somatic dysfunctions associated and the regions that you treated in the assessment.

00:42 And then utilize a 25 Modifier on the Evaluation and Management code to bill for your procedure code.

00:52 And make sure you bill appropriate procedure code for the OMT based on the number of regions that you treated.

00:59 So OMT is a procedure, it's important that every note has a procedure note with the findings clearly listed and the treatment modalities applied.

01:09 So you should list somatic dysfunction findings in your physical exam portion.

01:13 It could be incorporated by region or listed separately on each heading.

01:19 You ideally wanna list it by region since when you're billing and coding, is based on treatment of a particular region.

01:28 Some EMR's have now the ability for templates by region which will help you sort out the eventual coding.

01:38 There's a movement to document the severity of the dysfunction and it's response after treatment.

01:43 It's been implemented in some practices and recommended but is not a requirement at this time.

01:48 There's been prior audits in tha past where the physicians were denied claims because they lack documentation on the specific type of OMM they performed such as HVLA or counterstrain.

02:02 Since then, it has been rescinded but it is probably of good practice for you to list specific techniques that you used and not just say "Somatic dysfunction treated with OMT." Documentation is the same whether or not it's outpatient or inpatient.

02:18 You want to try to keep the diagnosis and documentation pertinent to the patient's presentation and chief complaint.

02:25 So here is an example of a proper osteopathic structural exam documentation.

02:31 And so, this could be an example for a patient that's presenting with headache.

02:36 So we examine the head, we found a OA dysfunction that was pretty severe so it was rated a 3 and then after a treatment of muscle energy it dropped down to 1 which is more mild.

02:48 We had some cervical dysfunctions, we had a type 2 dysfunction that was a 2 and after HVLA, it completely resolved, so it's rated a zero.

02:57 We had a right SCM spasm, that started off as a 1 and after myofascial release it resolved to be a zero.

03:03 We had some rib restrictions.

03:05 So in the rib area, we had a right 1st rib inhalation dysfunction that started off as a 2 and when we treat it with Still's technique, it dropped down to zero.

03:13 and in the thorax we had a group curve that started off as a 1, and after FPR it resolved and became a zero.

03:19 So, this is enough detail by region the listed somatic dysfunction and what technique we applied to the dysfunction and the eventual response of the dysfunction to the technique.

03:34 So again, OMT is a procedure.

03:37 You want to include a post procedure note and state whether or not the patient tolerated and if there were any complications.

03:42 So an example would be: Patient evaluated and treated with OMT as noted, tolerated the procedure well, had a decreased pain, increased range of motion after procedure.

03:53 When documenting your assessments, you want to list the assessment of your patient's medical diagnosis first.

03:59 So if your patient came in with a headache, that's the first thing you come in.

04:03 Patients don't come in with a diagnosis of "Hey, i have a cervical somatic dysfunction." So, the patient presentation should be first 'cause somatic dysfunction does not justify an office visit.

04:15 So an example here for your assessment would be headache first and then the different somatic dysfunctions based on region listed afer it.

04:25 So the ICD-10 codes for reporting somatic dysfunctions are in chapter 13.

04:31 There are M codes and connected to the musculoskeletal and connective tissue.

04:37 This replaced the ICD9 codes that started off with 739.

04:41 So here's a list of the ICD-10 codes.

04:45 They start with M99 and goes from 00 to 09, and again based on region.

04:51 So if I have a sacral dysfunction that I've diagnosed and treated, then I would code a M99.04.

04:58 So you should pick the codes that correspond with the region that you assessed, diagnosed and treated.