98926
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.69
Facility
$29.73
Non-Facility
$46.09
Documentation Required
- Medical record must include history and physical examination documentation demonstrating somatic dysfunction of one or more regions to support OMT coverage.
- When billing an E&M on the same date as OMT with modifier -25, documentation must clearly support that the E&M was a significant and separate service with a distinct purpose beyond routine pre/post OMT work; different diagnoses are not required.
- Provider credentials and that the treating clinician is a qualified physician (typically osteopathic physician) should be documented when performing OMT.
- The medical record must support the medical necessity of OMT and be made available upon request; documentation must identify the body region(s) treated and justify the procedure code billed.
Key Coverage Criteria
- Osteopathic manipulative treatment (OMT) is covered when medically necessary and performed by a qualified physician for patients whose history and physical examination document somatic dysfunction of one or more regions.
- Evaluation and management (E&M) services may be reported separately on the same date as OMT using modifier -25 when the E&M represents a significant, identifiable service above and beyond the usual pre- and post-service work for the OMT and this is appropriately documented.
- Osteopathic manipulative treatment (OMT) is covered when medically necessary to treat somatic dysfunction documented by examination findings describing pathology in skeletal, arthrodal, myofascial structures or related vascular, lymphatic, or neural elements.
- OMT is covered when provided to hospitalized patients if the treating physician determines it is medically necessary and the medical record supports that decision.
- Evaluation and management (E&M) services are separately payable with OMT only when a significant, separately identifiable E&M service is documented in the record; when applicable report modifier 25 on the E&M service.
- Multiple body regions may be treated in a single OMT session when examination documents compensatory changes and provides a rationale for treating each additional region.
11 Active Policies
A56954 — Billing and Coding: Osteopathic Manipulative Treatment
J06
L33616 — Osteopathic Manipulative Treatment
J06
UMR-POL-UMR-manipulative-therapy — Manipulative Therapy
SUREST-POL-SUREST-manipulative-therapy — Manipulative Therapy
BCBSIL-THE803.010 — Physical Therapy (PT) and Occupational Therapy (OT) Services
Related Codes
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