Evaluation and Management Services with Osteopathic Manipulative Treatment

Reimbursement Policy:
Evaluation and Management Services with Osteopathic Manipulative Treatment

Effective Date:
July 27, 2015

Last Reviewed Date:
February 23, 2023

Purpose:
Provide guidelines for the reimbursement of Evaluation and Management (E&M) Services performed in conjunction with Osteopathic Manipulative Treatment when billed by professional providers.

Scope
All products are included except for

Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
Commercial COB or as noted below.
ITS Home Local business Par
ITS Home National Accounts Par
MPL Non-Par
Flex link
ITS Host MA non-PPO
ITS Host MA PPO Non-Par

This policy applies to insured and Administrative Services Only (ASO) accounts.

Definitions:
Osteopathic Manipulative Therapy (OMT) is a form of manual treatment applied by a physician or other qualified health care professional to eliminate or alleviate somatic dysfunction and related disorders. This treatment may be accomplished by a variety of techniques.

For purposes of OMT the body regions include:

head region
cervical region,
thoracic region,
lumbar region,
sacral region,
pelvic region,
lower extremities,
upper extremities,
rib cage region,
abdomen and viscera region

Policy

OMT E & M Services: According to (Current Procedural Terminology (CPT) guidelines, an E & M service may be reported in addition to OMT if the member’s condition requires a significant, separately identifiable E & M service that is above and beyond the usual pre-service and post service work associated with the OMT. In such instances the provider should append modifier 25 to the E & M code and ensure that the appropriate documentation is included in the patient’s medical record in accordance with Center for Medicare and Medicaid Services (CMS) guidelines. It is appropriate to separately and additionally report an E & M service only in the following conditions:
1. Initial evaluation of a new member or condition; or a reevaluation of an established patient’s progress under a current treatment plan.
2. Acute exacerbation of symptoms or a significant change in the member’s condition; or
3. A distinct and different indication which is separately identifiable and unrelated to the manipulation.
When reporting an E & M service as separate to the OMT for any of the three (3) reasons cited above, the provider should append modifier 25 to the E & M code. If modifier 25 is not appended, the E & M service will not be reimbursed as per NCCI Edits.
An E & M service for a new patient visit (see 6. A. below) is reimbursable once every three (3) years.
An E & M service is reimbursable when one or more of the indications in section 1 above exist and medical records are submitted in support of the claim.
Level 2-5, E & M codes (99202 – 99205) are used to bill an office visit for the evaluation and management of new patients; and Level 2-5, E & M codes (99212 – 99215) are used to bill these services for established patients.
Definitions/clarifications for the above Policy statements
1. A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
2. An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
3. The level of E & M service reported should be consistent with the complexity of the history, physical examination and medical decision making involved in the member encounter as outlined in the American Medical Association CPT Manual and CMS guidelines and the diagnoses submitted on the billing or claim form must support the complexity of the service rendered.
4. Medical Records Documentation for E & M services claims:
  1. Medical record documentation will be requested and reviewed to support all claims that are submitted with E & M codes. No such claims will be approved without the required medical record.
5. Documentation in the member’s medical record should include the key components as well as the reasons for performing the separate E & M service. Documentation must meet CMS requirements on this matter.

Claim Submission guidelines
All regions treated must include a corresponding diagnosis code on the billing or claim form.

Medical record documentation must be supplied to support the submission of all E&M codes, regardless of level.

Procedure
Claims submitted with an E&M code that are not accompanied by supporting medical record documentation will pend while medical record documentation is requested and reviewed to support the level of E&M coding. Upon review of the medical record documentation, if the E&M service is not supported it will be denied.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
Mandated or legislative required criteria will always supersede.

CPT® is a registered trademark of the American Medical Association.

History:
6/4/2014: Policy approved
4/23/2015: Content revised to better convey episode of care and submission of medical records information. No changes to the policy guidelines or procedures.
2/24/2016: Split single policy into 2 distinct policies: one for CMT and one for OMT. No changes to policy guidelines or procedures.
2/22/2021: Deleted reference to "Level 1" and procedure codes 99201, 99211 from #5 in "Policy" section.
11/22/2021: Deleted "ITS Host MADV," added "ITS Host MA non-PPO," "ITS Host MA PPO Non-Par" in "Scope" section.

Policy 097_v6.0_02232023