L29246-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Osteopathic Manipulative Treatment (L29246)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29246

LCD Title

Osteopathic Manipulative Treatment

Contractor's Determination Number 98925

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity

Indications:

Osteopathic manipulative treatment (OMT) is a distinct manual procedure employed by a physician that aims to optimize a patient’s health and function. OMT is defined in the Glossary of Osteopathic Terminology as the therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that have been altered by somatic dysfunction. There are numerous types of physician performed manipulative treatments that make up OMT. The method employed by the physician is determined by the patient’s condition, age and the effectiveness of previous methods of treatment.

Somatic dysfunction is defined in the Glossary of Osteopathic Terminology as: Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using OMT. The positional and motional aspects of somatic dysfunction can also be described using at least one of three parameters:

1.) The position of a body part as determined by palpation and in reference to its adjacent define structure, 2.) The directions in which motion is freer, or

3.) The directions in which motion is restricted.

The diagnosis of somatic dysfunction is made by determining the presence of one or more findings, known as

T.A.R.T. (Tenderness, Asymmetry, Restriction of Motion and Tissue Abnormality). Osteopathic manipulative treatment includes thrust (active correction), muscle energy, counterstrain, articulation, myofascial release, visceral and cranial technique.

Somatic dysfunction in one region can create compensatory somatic dysfunction in other regions. Osteopathic manipulative treatment can also be used to treat the somatic component of visceral disease and any organ system. This component can manifest as changes in the skeletal, arthrodial and myofascial tissues. (Example: tight right shoulder muscles in a patient with gallbladder disease). Normalizing musculoskeletal activity (relaxing tense muscles, etc.) can normalize outflows through sympathetic or parasympathetic autonomic nervous systems to visceral systems, resulting in more normal visceral and any organ system function.

Osteopathic Manipulative Treatment is medically necessary when performed by a qualified physician who has examined the patient and determined that there is somatic dysfunction in one or more body regions and documented this in the medical record.

Limitations:

Osteopathic Manipulative Treatment is not covered when the indications of coverage are not met and when the documentation of a somatic dysfunction is not present in the medical record.

Definitions:

The following is a more complete description of and examples of OMT techniques. Please refer to the AOAs Glossary of OMT terminology for more information.

Thrust (active correction): Moving a restricted joint in the direction it is resisting.

Example of Technique:

Physician slowly pulls joint in the direction it is resisting. Once at the point of muscle resistance, the physician continues to slowly pull against the muscle restraint, while applying a quick force localized to the area of resistance often resulting in a "pop" in the affected joint.

Reason for Applying:

Treats motion loss and impaired or altered functions of the body’s framework.

Effect of Treatment:

Immediate increase in range and freedom of motion.

Muscle Energy: Manipulative treatment in which the patient’s muscles are actively used on request from a precisely controlled position, in a specific direction, and against a distinctly executed counterforce.

Example of Technique:

The patient actively co-operates with the physician to contract a muscle or muscles, inhale or exhale, or move one bone of a joint in a specific direction relative to the adjacent bone.

Reason for Applying:

Applied to strengthen weak muscles, activate inhibited muscles, and strengthen short, tight muscles.

Effect of Treatment:

Mobilizes joints in which movement is restricted, stretches tight muscles and fascia, or fibrous tissue, that envelops the body beneath the skin, encloses muscles and groups of muscles, improves local circulation, and balances neuromuscular relationships to alter muscle tone and improve joint movement.

Counterstrain: Technique in which patient is placed in position of comfort, maintains the position for a period of time, then is assisted by the physician to slowly return to a neutral position.

Example of Technique:

Patient is placed in position of comfort for 90 seconds, then is slowly returned to a relaxed and neutral position.

Reason for Applying:

Applied to relieve the physical pain of patients suffering from "tender points", to relieve referred pain from active trigger points and to normalize imbalances in the autonomic nervous system.

Effect of Treatment:

Identifies tender points and positions the patient to eliminate the tenderness.

Articulation: Physician gently and repeatedly forces the joint against the restrictive barrier, intending to reduce the barrier and improve motion.

Example of Technique:

Physician moves the affected joint to the limit of all ranges of motion. As the restrictive barrier is reached, slowly, and firmly the physician continues to apply gentle force against the joint to the limit of tissue motion, or the patient’s tolerance to pain or fatigue. The articulation is slowly repeated several times, each time gaining increased range and improved quality of motion.

Reason for Applying:

Most often applied to postoperative patients and elderly patients suffering from arthritis.

Effect of Treatment:

Enhances the effect of passive articulating motion by resisting it or permitting increased range of motion.

Myofascial Release: Also referred to as MFR, this procedure to designed to stretch and reflexly release patterned soft tissue and joint-related restrictions.

Example of Technique:

Physician twists, shears, and compresses joints while simultaneously feeling tissue and joints for shifting tightness and looseness.

Reason for Applying:

Applied to patients suffering from muscle tightness.

Effect of Treatment:

Joint-related movements are assessed and treated simultaneously. Joint and muscle movements are improved and pain is decreased.

The following is a complete description of Somatic Dysfunction. Please refer to the AOAs Glossary of OMT Terminology for more information.

somatic dysfunction: Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment. The positional and motion aspects of somatic dysfunction are best described using at least one of three parameters: 1). The position of a

body part as determined by palpation and referenced to its adjacent defined structure, 2). The directions in which motion is freer, and 3). The directions in which motion is restricted. See also T.A.R.T. See also S.T.A.R.

acute s. d., immediate or short-term impairment or altered function of related components of the somatic(body framework) system. Characterized in early stages by vasodilation, edema, tenderness, pain and tissue contraction. Diagnosed by history and palpatory assessment of tenderness, asymmetry of motion and relative position, restriction of motion and tissue texture change (T.A.R.T.). See also T.A.R.T.

chronic s. d., impairment or altered function of related components of the somatic (body framework) system. It is characterized by tenderness, itching, fibrosis, paresthesias and tissue contraction. Identified by T.A.R.T. See also T.A.R.T.

linkage, dysfunctional segmental behavior where a single vertebra and an adjacent rib respond to the same regional motion tests with identical asymmetric behaviors (rather than opposing behaviors). This suggests visceral reflex inputs.

primary s. d., 1. The somatic dysfunction that maintains a total pattern of dysfunction. See also key lesion. 2. The initial or first somatic dysfunction to appear temporally.

secondary s. d., somatic dysfunction arising either from mechanical or neurophysiologic response subsequent to or as a consequence of other etiologies.

type I s. d., 1. A group curve of thoracic and/or lumbar vertebrae in which the freedoms of motion are in neutral with side bending and rotation in opposite directions with maximum rotation at the apex (rotation occurs toward the convexity of the curve) based upon the Principles of Fryette. (American usage). 2. Second degree 22 dysfunction based upon the Laws of Lovett (French usage).

type II s. d., 1. Thoracic or lumbar somatic dysfunction of a single vertebral unit in which the vertebra is significantly flexed or extended with side bending and rotation in the same direction (rotation occurs into the concavity of the curve) based upon the Principles of Fryette (American usage). 2. First degree dysfunction based upon the Laws of Lovett (French usage).

somatogenic: That which is produced by activity, reaction and change originating in the musculoskeletal system.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

98925 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); 1-2 BODY REGIONS INVOLVED

98926 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); 3-4 BODY REGIONS INVOLVED

98927 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); 5-6 BODY REGIONS INVOLVED

98928 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); 7-8 BODY REGIONS INVOLVED

98929 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); 9-10 BODY REGIONS INVOLVED

ICD-9 Codes that Support Medical Necessity XX000 Not Applicable

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

The medical record documentation should include a history and physical. If an E/M service is being reported on the same day as OMT, the documentation should clearly distinguish the services that constitute the E/M service and the OMT service. The documentation should clearly identify the body regions affected and treated with OMT in order to justify the procedure code billed and the medical necessity of the service being performed. Medical records must be made available to Medicare upon request.

The selection of body region to which OMT is applied should reflect the region of documented somatic dysfunction. There may be instances when multiple regions are treated due to the occurrence of compensatory changes. When this occurs, the documentation should describe the compensatory changes and the rationale for

treating this area, especially if the patient has no complaints related to this area. Treatment should be directed to the areas of documented somatic dysfunction and should not be aimed at areas unrelated to the diagnosis. The type, frequency and duration of OMT should be consistent with current standards of medical practice.

Appendices

Utilization Guidelines OMT procedure codes should be reported based on the number of body regions involved that were treated. The medical record documentation should clearly note the body regions treated, which would justify the procedure code billed. Factors that may affect frequency and duration of treatment are: severity of illness, duration or chronicity of the patient’s condition and the presence of co-morbidities. These factors should be reflected in the medical record if they contribute to the physician’s treatment approach. Body regions referred to are:

• Head region

• Cervical region

• Thoracic region

• Lumbar region

• Sacral region

• Pelvic region

• Lower extremities

• Upper extremities

• Rib cage region

• Abdomen and viscera region

Only one OMT service should be billed per day, based on the description of the procedure code.

All medical treatment has a goal. If a response is not seen within a reasonable timeframe then other treatment options should be considered. The following are treatment guidelines and not rules:

A.) Acute phase OMT should be individualized and performed as necessary during the first month. If there is failure to progress then the treatment needs to be modified.

B.) Subacute phase OMT should be performed as necessary to maintain the improvement trend but at less frequent intervals unless there are extenuating circumstances that are documented in the medical record. Once the patient’s condition has plateaued, treatment enters the chronic phase.

C.) Chronic phase OMT involves chronic illness or condition such as chronic pain syndrome with depression, post- polio syndrome and malignant disease, should be as necessary, but not expected to be more than two times per month unless explained in the medical record.

D.) It is understood that there can be exacerbations of chronic conditions, which can and should be treated to return the patient to a level of maximum functioning.

It may be appropriate to perform OMT on a patient who is hospitalized if the physician feels it is medically necessary to the patient’s treatment. The medical record should support this treatment decision.

Evaluation and management services may be reported on the same day as OMT. A –25 modifier should be appended to the E/M code. The E/M code should be reported only if the patient’s condition requires a significant, separately identifiable E/M service, above and beyond the usual pre-service or post- service work associated with the patient’s condition. (See coding guidelines attached to this LCD)

Sources of Information and Basis for Decision

American Osteopathic Association (2006). Position paper on Evaluation and Management services (E/M) with Osteopathic Manipulative Treatment (OMT).

American Osteopathic Association (1998). Protocols for Osteopathic Manipulative Treatment (OMT).

American Osteopathic Association (2002). Glossary of Osteopathic Terminology. Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with

advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29246) replaces LCD L25290 as the policy in notice. This document (L29246) is effective on 02/02/2009.

Reason for Change