Osteopathic family physicians
need to be both
highly skilled in medicine and practice management.
By Douglas J. Jorgensen, DO, CPC
With
the advent of managed care, the simplistic notion of submitting
a claim for services rendered and expecting to get paid
is all but gone. Today, in addition to being skilled physicians,
we must also be savvy businesspersons. That means learning
your payor mix, knowing your coding issues and documenting
appropriately as you await the inevitable argument over
payment.
Many people are coding and documenting in error out of fear or misguided information
creating inconsistency on both sides. As osteopathic physicians, we need to
unify our effort by coding and documenting correctly, consistently and uniformly.
Therefore, let us look at an issue in need of focused attention.
OMT codes are Current Procedural Terminology (CPT) codes designed to reimburse
us for performing manipulative medicine on our patients (Table
1). They are broken down by numbers of regions and are intended to correlate
with the somatic dysfunctions ICD-9-CM codes regarding the specific regions
treated (Table
2).
The more somatic dysfunctions diagnosed and treated create a higher relative
value unit (RVU) assignment and subsequently increases reimbursement. Many
providers traditionally underestimate the number of regions treated or do not
bill for them at all.
Additionally, they often omit an evaluation and management code (E&M),
which is your office visit/consult code. In the OMT section of CPT, it states
the E&M service maybe caused or prompted by the same symptoms or condition
for which the OMT service was provided. As such, unrelated diagnoses are not
required for reporting OMT and E&M services on the same date.1
Although some providers or their physician-hospital organizations (PHO) have
unknowingly or unintentionally capitated OMT services with other acute/chronic
care issues, many have not. Others are told by the payor that it is a capitated
service, when in fact it is not.
Careful evaluation of your contracts is imperative. Consider legal counsel
as well as utilizing your state medical association and specialty college’s
resources. If you are in a capitated system where OMT has been included, renegotiation
is possible, but you may need to wait for the renewal period of your contract.
Fee for service and not capitation is the optimal reimbursement option for
OMT.
Another tactic by some payors is to argue that you cannot be reimbursed for
OMT because you are not a specialist. This would be equivalent to saying you
cannot be reimbursed for reading an electrocardiogram because you are not a
cardiologist.
The CPT text clearly states that ‘(a)ny procedure or service in any section
of this book may be used to designate the services rendered by any qualified
physician.2 Furthermore,
as osteopathic physicians we are trained in manual medicine as part of our
medical training. At times, this must be pointed out to the payors.
Documentation
This article focuses on how to bill for OMT services with and without E&M
services instead of a comprehensive overview of the federal documentation guidelines.
The latter should be a familiar part of every provider’s daily practice.
If it is not, education in this arena is imperative to avoid federal, state
and private payor sanctions via audits as well as optimizing your reimbursement.
When documenting OMT, use the documentation guidelines three key components
of history, examination and medical decision making (MDM). The 1995 guidelines
should be utilized for two reasons. They are simpler to interpret and apply
and the proposed E&M guidelines will be modeled more closely after these.
The 1997 guidelines’ complex and onerous examination requirements resulted
in numerous federal studies finding poor compliance.3 Fortunately,
the history and MDM are virtually identical for the 1995 and 1997 guidelines
so you need only know the physical examination issues for 1995 to implement
them. These are outlined in Table
3.
The history should have a chief complaint, history of present illness, review
of systems and a past medical, family and/or social history. Your physical
examination would include your musculoskeletal structural examination and any
germane body area or organ systems. The history and physical examination should
contain information germane to the complaint or be part of a workup to rule
out specific pathology. One should not add components to the history or physical
simply to enhance the documentation. That is upcoding and is fraud.
What more often occurs is that components of the history or physical that were
negative, are omitted to save time and these elements are very much germane
as they help with the differential diagnosis process. Furthermore, they add
elements to your documentation that could legitimately enhance your documentation
and subsequently your scoring to get your E&M code.
The MDM must evaluate the number of diagnoses, the amount of data to be reviewed
and the level of risk involved depending on the type of problems found as well
as medical and/or therapeutic intervention needed. Once the history, examination
and MDM are scored an E&M code is assigned.
Evaluation & Management
Codes
Consults come in two types: outpatient consults (99241-99245) and confirmatory
consults (99271-99275). The first type (99241-99245) is used when another provider
sends someone to be evaluated and treated. The confirmatory consult is for
a new patient with a specific complaint, but you could use the outpatient codes
for a new patient (99201-99205) also.
Confirmatory consults are acceptable and are assigned a more optimal RVU designation
than new patient codes. It need not be a second opinion or a true ‘confirmatory
consult’ to use these codes. However, if you use the consult codes you
must send a letter to the referring provider.4
A ‘cc’ or photocopy of your note is unacceptable unless you send
a letter or fax stating you saw the patient and that your note is en route.
This can be a form letter (see
Figure 1), but even if the referring doctor is within your group practice,
a written response from the consultant is still required.5 Lastly,
dictating your office visit into letter format provides another option.
Finally, if this is an established patient in your practice or you are seeing
a consult in follow up, you can still code an E&M (99212-99215-providers
should never bill a 99211 for their services) service with your OMT codes.
The American Association of Osteopathy and the American Osteopathic Association
support this as you need to diagnose before you treat the patient. This point
is hotly debated by many payors and doctors alike.
However, the –25 Modifier must be used with the E&M code to get paid
for both OMT and E&M. Some visits may warrant only coding the OMT codes
without E&M codes, but this should not be the rule. Furthermore, the OMT
codes were neither designed nor intended to be used alone as one can see by
the RVU assignments. Therefore, code your visits accordingly and learn your
reimbursement mix from your payors to make more sound business decisions.
If you are doing hospital based OMT too, the dictation system suffices for
your written reply to the referring provider. Make sure there is a written
request in the chart prior to you seeing the patient, otherwise you may not
get paid or be viewed as seeing the patient fraudulently.6
The hospital inpatient consult codes are acceptable (99251-99255) for the first
visit, but subsequent hospital care codes (99231-99233) and not follow up consult
codes (99261-99263) should be used for subsequent visits. Lastly, if a patient
is on observation and not fully admitted, the outpatient consult codes are
to be used.
Regardless of inpatient or outpatient consults, treatment (i.e.: OMT) may be
initiated at the time of consultation as long as the procedure (OMT codes)
is medically necessary and documented appropriately.7
-25 Modifier
Modifiers are designed to better describe a code or how that code is being
used in conjunction with another code or modifier. The –25 Modifier is
for a significant, separately identifiable evaluation and management service
by the same physician on the same day of the procedure or other service.8 Typically
it is used for two unrelated problems such as a treating a UTI at the time
of an excisional biopsy.
The E&M service for the UTI would be modified (e.g.: 99213-25) and the
biopsy would be coded without a modifier. The biopsy would be listed first
on the encounter form and the insurance routing form (and subsequently first
in your dictation/office note) and the UTI would be listed second. This is
critical for correct coding and reimbursement.
With OMT, the diagnosis somatic dysfunction is listed first with the correlating
ICD code(s) and CPT code without a modifier. The second, third and/or fourth
diagnoses are listed and these justify or create medical necessity for the
E&M service billed (your consult, in or outpatient codes). The E&M
code gets a modifier here just like the UTI example, but the E&M code need
not be for a separate problem and can in fact be what prompted the OMT.9
In your note or dictation, putting ‘Somatic Dysfunctions as noted above’ is
acceptable as you are referencing what you already described in your structural
examination. However, make clear your physical findings by putting ‘T5
Sidebent left Rotated right’ or ‘anteriorly rotated left ilium’ instead
of thoracic and ilial lesions. Precision avoids ambiguity, and creates less
room for an auditor to misinterpret your notes and findings. Furthermore, it
creates better medical records for your patients, colleagues and yourself.
Summary
Correct coding and documentation is a dynamic process that should be part of
a larger compliance plan within your practice. With some practice and frequent
education to stay abreast of current changes, correct coding and documentation
is not only possible but will enhance your practice by optimizing your reimbursement
and minimizing your risk.
Douglas Jorgensen,
DO, CPC is a family physician with Manchester Osteopathic
Healthcare in Manchester, Maine. He is a Certified Professional
Coder, and the founder of Jorgensen Consulting, a national
professional service organization offering educational
forums and coding consultation. He can be contacted via
e-mail at ems@ctel.net.
If you have any coding questions that you would like Dr. Jorgensen to answer
in upcoming publications, e-mail them to the ACOFP
Publications Department.
References
Gordy, K. Ed,; Current Procedural Terminology;
American Medical Association, Chicago, p. 450, 1999.
Gordy, K. Ed,; Current Procedural Terminology;
American Medical Association, Chicago, p. 450, 1999.
Rudolf, Paul; June 22, 2000 Town Hall
Presentation
Medicare Carrier Manual Section 15506,
Paragraph A, Parenthetical Phrase 3 (MCM 15506 A.3) and MCM
15506 I. 1.
MCM 15506 C.
MCM 15506 A. 2., I. 2.
MCM 15506 B.
Gordy, K. Ed,; Current Procedural Terminology;
American Medical Association, Chicago, p. 455, 1999.
