Running Your Practice

AOA and Maine DOs team up on audit prevention

Recent audits in the northeast U.S. have focused on OMT codes. Learn why and what you can do to successfully withstand an audit.


In late 2014, the National Government Services (NGS), the Medicare Administrative Contractor (MAC) for the northeast United States, began examining use of OMT codes (98927, 98928, 98929)—and, in some cases, reducing payment. Some wondered if DOs were being unfairly targeted for audits.

The AOA and the Maine Osteopathic Association teamed up to address the issue and protect osteopathic practice. Here are five questions you need to know:

1. Are DOs being targeted?

The NGS is looking at the use of OMT codes, but not specifically targeting all DOs. Osteopathic physicians in Maine account for 18.3% of all national Medicare claims for CPT Code 98929 (OMT to 9-10 body regions). Among all osteopathic manipulative medicine/neuromusculoskeletalnedicine specialists, 11% practice in regions covered and reviewed by NGS.

2. What is being audited?

There have been three waves of audits from NGS. In the first audit, NGS reviewed OMT codes and down-coded the level of OMT reported for a number of claims (it should be noted that E/M services reported on the same date of service were only rarely denied). The second audit was conducted as part of a CMS required “small widespread service review” which reviewed the higher level OMT codes (98927, 98928, and 98929). A third audit is starting, which is part of the normal auditing process for outlier utilization of codes. As part of the 2015 audit, there were several common reasons for denials:

  1. No documentation for the specific type of OMT performed (HVLA, counterstrain, etc.). This has since been rescinded.
  2. Repetitive treatment of chronic patients for more than 6 months, deemed to be “maintenance” care.
  3. Failure to document functional improvement or decline, especially in patients seen repeatedly over an extended period of time as noted above.

3. How has the AOA been involved?

Since October 2014, the AOA has been working with the Maine Osteopathic Association and physicians in New York, Connecticut, Vermont, Massachusetts and Rhode Island to advocate for the reversal of NGS audit determinations. In August 2015, AOA President-elect Boyd R. Buser, DO, and AOA staff met with 10 NGS reviewers and the medical director to educate them about osteopathic medicine, discuss the differences between OMT and other forms of manipulation, demonstrate OMT, and review OMT and CPT code development and documentation.

Dr. Buser and the Maine Osteopathic Association have been working with NGS to help them understand the medical use of higher level OMT codes. Some physicians were denied payments for the sole reason of not specifying the type of OMT provided. While those denials were reversed, including the type of OMT provided is being considered for the planned future revision of the Local Coverage Determination (LCD) for the OMT codes. NGS has agreed to engage the osteopathic profession in the revision process.

Meanwhile, the AOA has contacted CMS leadership regarding our concerns with the NGS audits. CMS last responded that they are looking into the issue of providing guidance for Evaluation and Management Services provided on the same day as OMT.

4. What can I do to respond to an audit?

Documentation is the key to withstanding an audit. If you are audited and your payment is denied or down-coded, the first level appeal is to respond in writing with a letter and seek redetermination. Second level appeals are to a Qualified Independent Contractor (QIC). The last level of appeal is to an Administrative Law Judge (ALJ).

The normal appeals process should be followed unless the only reason that the payment was denied was because the OMT was not specified. Those cases will be rescinded..

5. What are some tips to successfully withstanding an audit?

  • Report E/M Services with Modifier -25 and OMT, if performed on the same day
  • Ensure that you have thoroughly documented the history of the chief complaint, onset, frequency, duration, etc.
  • Document somatic dysfunction
  • Detail the regions treated with OMT
  • Include all of the techniques used and describe how the patient tolerated the treatment
  • Contact AOA staff for additional assistance.
    • Final note: Medicare does not pay for maintenance of care.

      For questions about audits, please contact Monica Horton, Director of Physician Services and Payor Relations, at


  1. Dawn Dillinger, DO

    We cannot even begin to claim that there is equality between MDs and DOs when this type of payment denial is in place, regardless of the unification of ACGME. This is not just happening in Maine or just the east coast but happens everywhere! I cannot, even if I provide research, get US Military Tricare insurance to cover OMT! I cannot get Medicaid to agree to pay more than about $13 for OMT regardless of the number of regions. There should be no modifier necessary, even though I use one. If we are truly using OMT as we are taught, it absolutely should be within the context of a medical office visit for a concern such as influenza or pneumonia. The AOA needs to put this advocacy at its forefront and be more concerned about it. Whether DOs want to consider OMT a defining characteristic of osteopathy or not, we are all taught it, there is plenty of research to back up its use and we should get appropriately paid for it across the country!

    1. Jack Forbush, DO

      It would seem that there are more important issues taking precedence or perhaps a greater degree of politic-ing is requiring. I wonder what would happen if this involved skin biopsies or some other procedural service.

  2. Lawrence Uhrig, D.O.

    I have been treating my patients with Osteopathic Diagnosis and Treatment for 27 years now and have dealt with the whole spectrum of problems like this, although I was lucky enough to avoid audits. While documentation is always said to be key to avoiding audits, the time involved for those of us who still write progress notes is overly demanding to give them all of what they want. I developed check lists for my charts but it doesn’t apply to all patients in all circumstances. Many insurers try to reclassify OMT codes as chiropractic or physical therapy procedures to justify their denying or limiting payment. This is actually insurance fraud on their part if they intentionally alter billing codes to avoid or limit payment. Physicians need to recognize and follow up on this abuse. The extra coding for quality coding for the govt, specific additional requirements by some insurance companies and the increased govt regulations with Obamacare and meaningful use demands is way too much on we physicians who just want to treat our patients.

    How can any real D.O. spend appropriate time evaluation and treating their patients Osteopathically with all of this?

    Answer: You can’t.

    My solution, which has been the source of tremendous pleasure and increased time with my patients and a return to a stress-free practice, was to opt-out of Medicare and not bill any insurance at all. I keep my notes my way, spend all of my time with my patients and get paid in cash or check at the time of service. More doctors, especially ones who treat Osteopathically, need to return to the old days and stop this hassle with third party payers. All of your troubles drop away. Don’t over charge and your patients will love it!

    It’s not for everyone but if 30% of the few hundred of us left treating patients in the old fashioned traditional way would opt-out, we would re-invigorate a great group of Osteopathic physicians to continue the tradition in Still’s honor!

  3. Bill Foley, DO, MSc, - President of the Massachusetts Osteopathic Society

    My office has been audited by NGS more than once. It is time consuming and wasteful. Because of this 2 of the 3 docs here have opted out of medicare. Most physicians manage and treat chronic problems so why can’t we. Using osteopathic treatments to alleviate chronic pain, even if temporarily, is a valid medical practice. Just like with HTN, DM, and other chronic diseases, routine follow ups are sometimes necessary to manage pain seen in incurable conditions like OA, fibromyalgia, and rheumatoid arthritis. I am happy the AOA and Dr. Buser are working on this problem.

  4. Gigi Levy

    I understand there is vote the end ofAugust that will determine in 12 states (in MA where I live) whether Medicare will cover osteopathic manipulation. I have had constant nerve pain in my Right leg and lower back. It took 4-5 months going once a week to my DO before the pain and my not being able to walk more than 3 feet improved. I have found that if I skip a week there is increase pain and I take a step backwards.
    I am 67 and I do not want to be addicted to opiates. If Medicare stops paying for this treatment, I will have to end up way sooner in a nursing home. That would cost a hell of more money than a treatment once a week.
    Please let me know where seniors can voice there concerns prior to this vote.

    1. Rose Raymond


      You can visit the website, an advocacy site specifically set up to help people voice their concerns about these proposed changes. Once you’re on the site, you can click on the tab that says “Patients” to find sample copy tailored to you. Many thanks.

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