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OMT Coding/Billing

Documentation and Coding for OMT

What documentation must show in order to get paid by MEDICARE? *medical necessity
Current uses for medical documentation ? *document patient care *legal protection *Improves reimbursement *Osteopathic research *HIPAA/Privacy
Discuss the three components necessary to assign E/M code levels? *E/M = evaluation and management based on physician encounter *E/M codes are how outpatient visits are coded to get paid * the 3 components are:History, Physical Examination, Medical decision making (MDM)
What some things that need be be included with the three components ? *History :cc, HPI, ROS, PMH, OSE *Physical Exam: only pertinent to complaint, msk/osteo structural exam *MDM: number of Dx, problem risk level, and intervention needed
ICD-9 Codes are for ? * for each Diagnosis that was managed(International Classification of Diseases) *put in Assessment of SOAP note
How to get paid for both E/M and OMM ? * attach a 25 modifier to E/M code....Ex. 99999-25 *identifies a separate and identifiable procedure has been performed in addition to E/M
Concept of medical insurance bundling ? (reason behind the -25 modifier) * process by which payers group separately identifiable charges, as defined by CPT, and then pay for the “bundled” group at a lower rate than the sum of the individual charges *E/M and procedures should be paid individually, not lumped
Subjective info to put in E/M ? * all pt. verbal history and osteo structural Hx
Objective info to put in E/M ? * pertinent Sx exam and osteo structural exam
Assessment info ? * E/M = codes for each Dx *Osteo Somatic Dysfunction = for each somatic dysfct found in by regions *Add -25 modifier if another procedure was done
Plan ? * OMM - procedure/region * E/M- anything you gave them or told them to do *Follow-Up - time w/patient and visit summary
Created by: thamrick800