Transcript 12:15 PM: Billing / Coding

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
Documentation
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
98927 5-6 regions $55.82
98928 7-8 regions $65.09
98929 9-10 regions $75.12
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):2125.
• https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/eval_mgmt_serv
_guide-ICN006764.pdf
• http://www.thenationalcouncil.org/wpcontent/uploads/2013/01/ICD10MythsandFacts.pdf