Documentation and Coding for OMT
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| What documentation must show in order to get paid by MEDICARE? | *medical necessity
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| Current uses for medical documentation ? | *document patient care *legal protection *Improves reimbursement *Osteopathic research *HIPAA/Privacy
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| 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)
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| 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
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| ICD-9 Codes are for ? | * for each Diagnosis that was managed(International Classification of Diseases) *put in Assessment of SOAP note
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| 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
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| 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
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| Subjective info to put in E/M ? | * all pt. verbal history and osteo structural Hx
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| Objective info to put in E/M ? | * pertinent Sx exam and osteo structural exam
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| 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
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| Plan ? | * OMM - procedure/region * E/M- anything you gave them or told them to do *Follow-Up - time w/patient and visit summary
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thamrick800
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