When a patient comes to your office for a follow-up visit, is it enough to simply indicate “follow-up” as the reason for the encounter? What about “management of multiple medical processes?”
Both are examples of insufficiently specific documentation, according to Kavin Williams, AOA senior manager of coding and payment, who provided OMED attendees with coding tips and resources.
“Documentation is huge right now—if it wasn’t documented, it wasn’t done,” he explained, noting that all records should be detailed enough to hold up under an audit.
Here’s a look at the coding best practices to help get you there.
Basics of OMT coding
- Coding for somatic dysfunction hasn’t changed drastically under ICD-10. Code numbers have changed, but the regions of the body are the same as under ICD-9.
- Osteopathic manipulative treatment (OMT) codes are not time-based; you would code the same way for 45 minutes or 10 minutes of OMT.
- There’s no differentiation between OMT performed on the right or left side of the body; you simply need to indicate the area of the body where the treatment was performed (e.g. upper extremity).
- If you examine eight regions of the body, document that you’ve done so, and be sure your electronic medical record system allows you to capture that data.
- Remember that patients do not come to your office for OMT. They present for an injury, pain or other symptoms. Because OMT is a tool used in treating the patient’s diagnosis, your coding should reflect his or her underlying health complaints.
OMT coding mechanics
- To code for OMT, start by reporting the appropriate evaluation and management (E/M) service code, 99201-99215, based on your documentation.
- Append Modifier -25 to the E/M service code. Do not append Modifier -25 to the OMT procedure.
- Report the appropriate OMT procedure code (98925-98929) based on the findings of the physical exam.
- For more details on coding for OMT, Williams recommends DOs consult the AOA’s OMT coding manual or OMT policy.
- Documentation must include the reason for the encounter/chief complaint; history; physical exam findings/diagnosis; medical decisionmaking/plan for care; and a date and legible signature.
- Before coding anything, document your encounter with the patient.
- Keep in mind that the level you code must be based on the history, physical exam and medical decisionmaking that took place during the visit. “You can’t just say, this patient has chronic obstructive pulmonary obstructive disease—that’s a level 4,” Williams noted. “The code level is determined by the documentation.”
- If a payer informs you they’re denying your claims, start by looking at the explanation of benefits (EOB) in the letter they sent. You can appeal the decision, Williams said, though many times the result is that the payer continues to deny claims.
For assistance with denied claims, he urged physicians to contact the AOA’s Department of Practice Management and Physician Services.