LCD L33616

Coverage Guidance

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862(a)(7) excludes routine physical examinations unless otherwise covered by statute.

Indications and Limitations of Coverage

Abstract

Osteopathic manipulative treatment (OMT) is a distinct manual procedure employed by physicians, 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 has been altered by somatic dysfunction. OMT encompasses a wide variety of techniques, including but not limited to muscle energy, high velocitylow amplitude, counterstrain, myofascial release, visceral, articulatory, and cranial. The chosen treatment will vary depending on patient’s age, clinical condition and the effectiveness of prior methods of treatment. (Note: OMT is appropriately provided by a D.O. or by an M.D. who has been trained in OMT.)

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.

Indications

Osteopathic Manipulative Treatment is covered when medically necessary and performed by a qualified physician, in patients whose history and physical examination indicate the presence of somatic dysfunction of one or more regions (appropriately documented in the medical record) when such treatment is likely to result in improvement in the patient’s condition (e.g. less pain) or functional status. The diagnosis of somatic dysfunction is made by determining the presence of one or more findings described by the acronym TART (Tenderness, Asymmetry, Restriction of Motion and Tissue Texture Abnormality).

Somatic dysfunction in one region can create compensatory somatic dysfunction in other regions. Osteopathic manipulative treatment is also utilized to treat the somatic component of visceral diseases. This component can manifest as changes in the skeletal, arthrodial and myofascial tissues. (e.g., right shoulder pain and associated somatic dysfunction in a patient with gallbladder disease).

Note: Osteopathic Manipulative Treatment specifically encompasses only the procedure itself. E&M services are covered as a separate and distinct service when medically necessary and appropriately

documented.

Limitations

Osteopathic Manipulative Treatment is not covered when the indication of Coverage is not met, and conventional documentation of somatic dysfunction is not present in the patient's medical record.

No E&M service is warranted for previously planned follow-up OMT treatments.

Examples include:

• If a patient is scheduled for a defined number of follow-up OMT treatmentsfor an episode of care, no E/M should be reported on those dates of service unless a new condition occurs or the patient’s condition has changed substantially, necessitating an overall reassessment of the treatment plan;

• If a patient is seen and the E/M service determines that OMT is indicated, but the patient must be scheduled to receive the OMT the following day due to time constraints, no E/M should be reported on the following day unless the patient’s condition has changed substantially. The medical record should clearly document this.

Summary of Evidence

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Analysis of Evidence

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Bibliography

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