LCD Reference Article Response To Comments Article

Response to Comments: Osteopathic Manipulative Treatment

A55318

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
National Government Services, Inc.	MAC - Part A	06101 - MAC A	J - 06	Illinois
National Government Services, Inc.	MAC - Part B	06102 - MAC B	J - 06	Illinois
National Government Services, Inc.	MAC - Part A	06201 - MAC A	J - 06	Minnesota
National Government Services, Inc.	MAC - Part B	06202 - MAC B	J - 06	Minnesota
National Government Services, Inc.	MAC - Part A	06301 - MAC A	J - 06	Wisconsin
National Government Services, Inc.	MAC - Part B	06302 - MAC B	J - 06	Wisconsin
National Government Services, Inc.	A and B and HHH MAC	13101 - MAC A	J - K	Connecticut
National Government Services, Inc.	A and B and HHH MAC	13102 - MAC B	J - K	Connecticut
National Government Services, Inc.	A and B and HHH MAC	13201 - MAC A	J - K	New York - Entire State
National Government Services, Inc.	A and B and HHH MAC	13202 - MAC B	J - K	New York - Downstate
National Government Services, Inc.	A and B and HHH MAC	13282 - MAC B	J - K	New York - Upstate
National Government Services, Inc.	A and B and HHH MAC	13292 - MAC B	J - K	New York - Queens
National Government Services, Inc.	A and B and HHH MAC	14014 - HHH MAC	J - K	Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont
National Government Services, Inc.	A and B and HHH MAC	14111 - MAC A	J - K	Maine
National Government Services, Inc.	A and B and HHH MAC	14112 - MAC B	J - K	Maine
National Government Services, Inc.	A and B and HHH MAC	14211 - MAC A	J - K	Massachusetts
National Government Services, Inc.	A and B and HHH MAC	14212 - MAC B	J - K	Massachusetts
National Government Services, Inc.	A and B and HHH MAC	14311 - MAC A	J - K	New Hampshire
National Government Services, Inc.	A and B and HHH MAC	14312 - MAC B	J - K	New Hampshire
National Government Services, Inc.	A and B and HHH MAC	14411 - MAC A	J - K	Rhode Island
National Government Services, Inc.	A and B and HHH MAC	14412 - MAC B	J - K	Rhode Island
National Government Services, Inc.	A and B and HHH MAC	14511 - MAC A	J - K	Vermont
National Government Services, Inc.	A and B and HHH MAC	14512 - MAC B	J - K	Vermont

Article Information

General Information

Article ID
A55318

Article Title
Response to Comments: Osteopathic Manipulative Treatment

Article Type
Response to Comments

Original Effective Date
11/01/2016

Retirement Date
N/A

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Article Guidance

Article Text
As an important part of Medicare Local Coverage Determination (LCD) development, National Government Services solicits comments from the provider community and from members of the public who may be affected by or interested in our LCDs. The purpose of the advice and comment process is to gain the expertise and experience of those commenting.

Thank you for the overwhelming response during the period of Comment for the NGS policy draft Osteopathic Manipulative Treatment. By the close of the Comment period on Aug. 13th, NGS had received more than 2400 individual comments, and a much appreciated, overarching, set of comments and proposed revision from the American Osteopathic Association.

The official notice period for the final LCD begins on 09/16/2016, and the final determination will become effective on 11/01/2016.

Response To Comments

Number	Comment	Response
1	Many comments addressed the common theme of “limiting care by Osteopathic Physicians”, which has never been the intent of National Government Services.	NGS appreciates the value of Osteopathic Manipulative Services in the management of somatic dysfunction, and as an alternative to pharmacologic treatment in the management of pain. Also, NGS values the totality of services provided by Doctors of Osteopathy in both the Primary and Specialty care of patients in the U.S. and especially in the NGS jurisdiction. If you read the policy carefully, there is nothing that diminishes the ability of osteopathic physicians to perform the entire spectrum of services they are currently performing. However, on the basis of claims review and medical documentation review, and an accelerating Error Rate, it became apparent that a disparity was developing between some osteopathic physicians, and the further assembly of medical and surgical specialties, in the documentation and coding of concurrent E&M services. Most specifically, in the use of modifier -25, and the concurrent performance of Osteopathic Manipulative Services and Evaluation and Management Services, there appeared to be varied expectations and understanding of the requisite documentation. This issue has been addressed on several occasions over the years, and it is our understanding that CMS will address the valuation of the pre, intra and post service components of the Osteopathic Manipulative Service codes as part of this year’s Final Rule. The policy has been revised to emphasize the CPT definitions and CMS expectations of these services as its sole intent, and not to alter the delivery of medically necessary services.
2	Another common theme in the comments received was the concurrent performance of Osteopathic Manipulative Therapy and Evaluation and Management Services and the need for the E&M portion of encounters with patients.	As commenters correctly note, Evaluation and Management services are often performed concurrently and correctly with Osteopathic Manipulative Services. The weight and relationship of the pre, intra and post service components of the OMT codes, particularly when performed concurrently with E&M services, have historically been an ongoing discussion with CMS. It is our understanding that components and valuation of OMT will be reviewed again by CMS as part of this year’s final rule. This NGS policy in no way means to limit the appropriate, and medically necessary delivery of both cognitive, and manipulative, services to Medicare beneficiaries. It reaffirms the expectation that the documentation of these services per CPT and CMS is the same as for all other medical and surgical specialties.
3	The concept of a Plan of Care was questioned by many commenters, and has been removed from the finalized policy in favor of recommended language from the AOA.	Regarding the concept of a plan of care, call it the Plan (of a SOAP note), Treatment Goals or Medical Decision Making. There is no intent to confuse osteopathic services with other manipulative services. This is simply a recommendation to help delineate and simplify the documentation of the medical necessity should an osteopathic physician determine that a series of manipulative treatments be needed on the basis of a single evaluation. It has been the observation of medical reviewers that patients arrive with a documented chief of complaint,” here for OMT.” There is no additional documentation suggesting an evaluative service has been performed. This suggestion is to include the date/documentation of the prior evaluation so that the medical necessity is clearly established. When a practitioner deems it necessary to perform an evaluation, it is totally appropriate to do so, however, it is beyond the discretion of this contractor to alter the expectations of a service as defined by both AMA/CPT and CMS. We hope that this policy, as finalized, serves as a reminder of the expectations of the documentation of medically necessary services that providers are performing. As already stated, there is no intent to diminish the ability of responsible practitioners to perform medically necessary services, merely to review expectations of service definitions that are beyond our discretion.
4	Another theme common to many letters was the need to address the severe opioid crisis faced by the nation.	There appears to be significant misunderstanding of the intent of this policy, with regard to alternative therapy options to opiate use, and access to osteopathic manipulative therapy, in general. NGS agrees with the AOA (and others) regarding the importance of reducing inappropriate opiate prescribing. Please note that there are no barriers to the performance of OMT in the policy. There is simply a requirement that the need for the service is adequately documented in the chart, the choice of treatment modality is noted, and the response to the service is noted. This is a common expectation of all of the practitioners and specialties with which we deal.
5	Some commenters disagreed with provisions related to maintenance and duration of services, pointing out that OMT often decreases the use of other treatments that would otherwise be ongoing, including opioid prescription, and in many cases avoids the need for surgeries that would be much more costly than ongoing monthly OMT treatments.	Please see the alternative language developed in part with the help of the AOA, included in the finalized policy.
6	The question of the definition of, or documentation requirements of, coding established by CMS and AMA/CPT for E&M services was raised in many comments.	There are basic requirements to the documentation of both Osteopathic Manipulative Services and Evaluation and Management Services per AMA/CPT and CMS that are beyond the discretion of any contractor to alter. Similarly, the use and application of the -25 Modifier is not a contractor definition. We have no choice but to review services performed by Osteopathic Physicians in the same common “language” of all medical specialties.
7	Some commenters asked for a clear definition of improved symptoms or functional status.	Please see the alternative language, developed in part with the help of the AOA, included in the finalized policy.

Coding Information

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

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N/A

Group 1 Codes

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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N/A

Group 1 Codes

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ICD-10-PCS Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

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Associated Documents

Updated On	Effective Dates	Status
09/08/2016	11/01/2016 - N/A	Currently in Effect	You are here

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Response to Comments: Osteopathic Manipulative Treatment

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