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1/14/2014 M. Seffinger, DO, Course Coordinator, WesternU-COMP Required 3rd

Year OMM Rotation 1

Western University of Health Sciences

College of Osteopathic Medicine

of the Pacific

Osteopathic Manipulative Medicine

Preceptor Handbook

4th Edition


Year OMM Rotation 2

Table of Contents Page

Introduction 3

Freshman and Sophomore OMM Curriculum 4

The Required Junior OMM Clinical Rotation 4

Teaching OMM in Clinical Practice 9

Competency Evaluation in OMM 13

OMT SOAP Note Documentation Form 14

Coding 15

OMT Management Plan 19

Sample OMT Procedure Note (for students to use) 21

Sample OMT Procedure Check List (to assist in evaluation) 22

Required Case Presentation 23

Required Readings During Junior Year OMM Rotation 25


Year OMM Rotation 3

Introduction

This is the fourth edition of the Western University of Health Sciences

College of Osteopathic Medicine of the Pacific osteopathic manipulative

medicine (OMM) preceptor guidebook. It is meant to be a resource manual for

clinical preceptors training our junior and senior students in osteopathic

manipulative medicine. The first required OMM clinical rotation for junior

osteopathic medical students at COMP began in June 2001. Fortunately, we have

found many preceptors who are willing and able to provide our students with the

required training.

Students are now required to pass a standardized patient practical exam in

which OMM is integrated in the care of a patient, as well as an OMM written

exam as part of their evaluation of this rotation when they return to campus in a

month or two after their OMM rotation. They also are required to pass a national

practical exam on several standardized patients in whom OMM is integrated in

their management plan, as well as a national written exam that incorporates many

OMM test questions, before being eligible to graduate from COMP with a D.O.

degree. So, this 3rd

year clinical OMM rotation is vital for them to be able to learn

to integrate and apply their OMM knowledge and skills in a clinical setting.

Hopefully, many will want to take an OMM elective in their 4th

year as well in

order to strengthen their knowledge and skills further before the national exams.

I encourage you and your students to utilize the Foundations for

Osteopathic Medicine textbook, published by Lippincott, Williams and Wilkins in

2003. This is the only nationwide, multispecialty, peer-reviewed text on

osteopathic medicine, developed with the support of the AOA, for widespread

use. Selections from the following chapters or sections would be most

appropriate as assigned reading and discussion during the OMM rotation:

Philosophy; Basic Sciences and Behavioral Sciences Sections; Clinical Problem

Solving; Family Practice and Primary Care Section; Clinical Specialties Section;

Osteopathic Palpatory Diagnosis and OMT Section; and the Glossary of

Osteopathic Terminology.

Additionally, included in this handbook are some informational materials

and some forms useful in documenting, coding and billing for OMM services.

There are also some sample procedural forms for both the student and preceptor

to help keep track of accomplishments and to assist in evaluation of the student.

We hope you find them all to be useful resources.

Finally, at or near the end of the rotation, the student is a required to

give you a case presentation in both oral and written formats, at least on

PowerPoint, and then send a copy by email or fax to Dr. Seffinger at

COMP’s OMM dept. (email: [email protected]; Fax: (909) 469-

5289. If regular mail is the only way to send it in, then the student is to send

it to Michael Seffinger, D.O., OMM Dept., WesternU-COMP, 309 E. Second

St., Pomona, CA 91766-1854. These will be used to help develop the OMM

curriculum at COMP. Dr. Seffinger will gladly help any student interested

in publishing his or her case presentation.

mailto:[email protected]


Year OMM Rotation 4

Please feel welcome to share your ideas and needs with us so we can

develop more resources to assist you in your endeavors.

Freshman and Sophomore OMM Curriculum

In the first year, students are taught fundamental osteopathic structural

exam skills and introduced to the most common osteopathic manipulative

techniques as determined by the chair of the department. The basic OMM

curriculum is similar in all osteopathic medical schools and is largely determined

by the Educational Council on Osteopathic Principles (ECOP) of the American

Association of Colleges of Osteopathic Medicine (AACOM). Each school’s

OMM department chair has autonomy, however, to determine his or her curricular

agenda and coursework. The current OMM curriculum at COMP emphasizes the

following skills:

1) Osteopathic screening, regional and segmental structural exams to

diagnose primary and secondary somatic dysfunction;

2) Introduction to soft tissue, articulatory, muscle energy, HVLA,

counterstrain, myofascial release OMM techniques for each body

region and osteopathy in the cranial field, abdominal fascial releases,

lymphatic drainage techniques and Chapman’s viscero-somatic reflex

tenderpoints;

3) Introduction to, and critical reading of, osteopathic literature, both past

and current;

4) Osteopathic clinical problem solving through selected case vignettes in

small group settings;

5) Applications of osteopathic principles in practice and OMM for

patients having systemic dysfunction.

The Required Junior Year OMM Clinical Rotation

The junior year rotation provides the students with the opportunity to put

their developing osteopathic philosophy and principles and OMT skills into

practice with patients of various ages and problems. This often is the student’s

first, and hopefully not the only, opportunity to build confidence in themselves as

osteopathic clinicians capable of helping patients not only with their knowledge,

but also with their beliefs and values, as well as their skillful hands. Below is an

outline of goals, objectives, expectations and resources to help guide you as

preceptor in educating our students during this unique rotation.

Purpose of the Rotation

1. To provide students with an opportunity to apply osteopathic philosophy and

principles (OPP), osteopathic palpatory diagnosis and osteopathic

manipulative treatment (OMT) skills in clinical practice under the guidance of

experienced instructors.


Year OMM Rotation 5

2. To provide students with an opportunity to practice diagnosing and treating

somatic dysfunction and further their understanding of the relationship

between the musculoskeletal system and a variety of clinical disorders.

Goals –General

Each 3rd

year student will:

1. Gain an understanding of the relationships of somatic dysfunction to each

patient’s problems and its significance in each clinical situation.

2. Develop an appreciation of an integrative osteopathic approach to patient care,

including the utilization of palpatory diagnosis and osteopathic manipulative

treatment.

3. Learn to identify, treat and manage patients with somatic dysfunction in

various clinical situations.

4. Be able to perform OMT as appropriate with understanding of precautions,

indications and contraindications in each case.

5. Be able to document findings and procedures in standard format (as detailed

in Foundations for Osteopathic Medicine “FOM” textbook).

6. Integrate OPP in routine patient care.

Objectives:

At the end of the rotation, each 3rd

year student will demonstrate knowledge and

competence in the following:

1) Perform and document a standard osteopathic structural exam (see FOM) of

the neuro-musculoskeletal system inclusive of all body regions.

2) Document symptoms, objective findings, assessment of somatic dysfunction

and management plan in SOAP note format using standard nomenclature as

referenced in the osteopathic glossary of terminology published by the AOA

in its annual directory of physicians (now online at www.osteopathic.org or

www.do-online.org) and is also included in the back of FOM.

3) Specify in the assessment the region of the somatic dysfunction and its

relationship to the history as well as the chief complaint; i.e., state its

significance to the patient’s health.

4) Give each patient information regarding the OMT procedures proposed

(indications, diagnosis, type, method, side effects possible, precautions to be

used to minimize side effects, possible complications and how you are going

to prevent them) and obtaining patient permission prior to application of

OMT.

5) Perform direct and indirect OMT procedures in each body region. May use

any of the following or combinations:

a. A.T. Still techniques

b. Articulatory techniques

c. Autonomic balance/ganglia techniques

d. Facilitated Positional Release

e. Functional methods

f. HVLA

g. Lymphatic, liver and spleen pumps

h. Muscle energy

http://www.osteopathic.org/

http://www.do-online.org/


Year OMM Rotation 6

i. Myofascial Release

j. Soft tissue

k. Strain/Counterstrain

l. Sutherland’s balanced ligamentous tension techniques

m. Sutherland’s cranial-sacral approaches

n. Visceral techniques

o. Other techniques in FOM not listed above

6) Reassess each patient after OMT and document any observable changes.

7) Design management plans for each patient with somatic dysfunction,

including how often each patient should be treated, for how long, and any

exercises, lifestyle changes, and/or adjunctive therapies that would be helpful

in restoring normal structure and function. Also document the types of

treatment that were effective and those that were not and the dose required

(duration and/or force needed to effect a change).

8) Be able to define verbally, using both standard and simplified explanations,

the following terms (Use AOA Glossary of Osteopathic Terminology

available on their web site www.osteopathic.org and at the end of Foundations

for Osteopathic Medicine textbook 2nd

edition (2003):

a. D.O.

b. O.M.T.

c. Osteopathic medical student

d. Osteopathic Medicine

e. Osteopathic palpatory diagnosis

f. Osteopathic philosophy

g. Osteopathic Physician and Surgeon

h. Osteopathic principles

i. Osteopathic structural exam

j. Somatic dysfunction

9) State differential diagnoses of each somatic complaint and finding seen in

each patient and review with the preceptor.

10) Integrate basic science and medical information and training with osteopathic

palpatory and manipulative treatments.

11) Applications of osteopathic principles in systemic dysfunction as well as in

neuromusculoskeletal (somatic) dysfunction.

12) Applications of osteopathic principles to patients with acute and chronic pain

syndromes.

During the rotation, the student is expected to do the following:

1) Demonstrate professionalism and demeanor necessary for an office-based

primary care medical practice.

2) Attend clinic daily. If preceptor is not seeing patients for part or all of a day,

the student must be engaged in studying the required and other readings and

assignments between 8 a.m. and 5 p.m. The work done needs to be validated

by the preceptor in order to get credit for the time spent studying in lieu of

time spent in the clinic with patients.

3) Demonstrate ability to diagnose and treat somatic dysfunction.

4) Record subjective complaints, history, objective findings and procedures,

assessments, problem lists, management plans as per standard practices.

http://www.aoa-net.org/


Year OMM Rotation 7

5) Read required readings and discuss with preceptor.

During the rotation, the preceptor is expected to do the following:

1) Be an osteopathic physician mentor and role model for WesternU-COMP

students.

2) Provide patients willing to have students evaluate them with an osteopathic

structural exam and treat them utilizing osteopathic manipulative treatment.

3) Validate objective findings (Tissue texture abnormalities, Asymmetry of

structural position, Range of Motion abnormalities, Tenderness) and

diagnoses of somatic dysfunction.

4) Help students discover and learn the clinical significance of their findings and

diagnosis.

5) Facilitate students in gaining confidence in their palpatory and manipulation

skills.

6) Facilitate student usage of standard OMT medical record documentation

practices, using FOM and AOA resources on OMT documentation as guides.

7) Discuss applications of osteopathic philosophy, principles and practices to

patient evaluation, treatment and development of management plans to

address each patient’s problems.

8) Help students understand how to integrate osteopathic palpatory diagnosis and

OMT with the patient’s concurrent medical problems; including indications,

contraindications, dose, frequency, order and duration of osteopathic

manipulative treatments.

9) Stimulate utilization of required and assigned readings (see below).

10) If the preceptor is traveling, or if the office is closed for part of the week

during the rotation, it is the preceptor’s duty to assign the student to another

physician, clinical experience or provide guidance for homework assignments.

Evaluations

The evaluation of the student is based upon, but not limited to the following:

Knowledge of the basic and clinical scientific foundation for the osteopathic

philosophy of medicine.

Knowledge of osteopathic principles and their applications in clinical practice.

Preciseness and comprehensiveness of information gathered in history taking.

Thoroughness in gathering physical information using standard osteopathic

and general medical, laboratory and radiological evaluations.

Ability to develop an appropriate diagnosis of somatic dysfunction as it relates

to the patient’s other medical problems.

Accuracy and thoroughness of documentation of history, physical, assessment

and management plans in the medical record.

Ability to cooperate and display professionalism with patients and other health

care professionals.

Communication skills, rapport and attitude with patients and ancillary staff.

Attendance and participation.

Clinical case presentations.

Demonstration of knowledge obtained from readings.

Assessment of osteopathic manipulative treatment skills.


Year OMM Rotation 8

Required Readings:

1) Ward RC, Ex. Ed. Foundations for Osteopathic Medicine, Philadelphia:

Lippincott, Williams and Wilkins, 2003; chapters1, 2, 13, 15, 16, 17, 19 -73.

2) Seffinger MA and Hruby RJ. Evidence Based Manual Medicine: A Problem

Oriented Approach. Philadelphia: Saunders/Elsevier, 2007.

3) Nelson KE and Glonek T. Somatic Dysfunction in Osteopathic Family

Practice. Philadelphia: LWW, 2006.

Suggested Topics for Discussion with Preceptor:

1. Utility of palpatory findings in diagnosis

2. Viscero-somatic reflexes

3. Manipulative prescription (Dose, Frequency, Duration, Follow-up, Sequence,

Methods, Complementary therapies)

4. Indications and contraindications to various types of OMT

5. Enhancing respiratory, circulatory, neurological, metabolic, musculoskeletal

and psychological or behavioral functions

6. Applications of osteopathic principles and philosophy to various clinical

situations (can use FOM clinical specialties section or selections from

preceptor’s files or book collection for assigned reading as well).


Year OMM Rotation 9

Teaching OMM in clinical practice

OMM encompasses complete patient evaluation, considering differential

diagnoses, contraindications, precautions, awareness of the patient’s entire health

history and physical findings, and appropriate application of osteopathic

manipulative treatment as a primary or adjunct modality in the total and

comprehensive care of the patient. Teaching OMM entails psychomotor,

cognitive and emotional components. Psychomotor skill development, in general,

requires well coordinated and precisely controlled series of musculoskeletal

movements to produce a successful performance. Although some students are

mechanically inclined and perhaps naturally coordinated and adept at

psychomotor activities, most require training to develop their skills. In this light,

it is necessary for most students to have ample practice and repetition to develop

smooth and efficient OMM skills. We try to offer that opportunity in the first two

years of osteopathic medical training. However, since the students practice the

osteopathic manipulative treatment (OMT) procedures mostly on healthy and

asymptomatic peers in the classroom, they have not yet developed a sense of the

effectiveness of OMM, and thus typically lack self-confidence. Experiencing the

effectiveness of OMM on ill patients will build self-confidence and help promote

utilization beyond medical school. During the junior year clinical OMM rotation,

we feel that having a student evaluate and treat with OMT at least 6 patients per

day, 5 days a week, for 4 consecutive weeks will provide ample opportunity to

develop effective OMM skills and build confidence.

Cognitive aspects need to be developed as well. A student needs to be

able to visualize and verbalize the anatomical and physiological dysfunction that

accounts for the patient’s complaints or abnormal findings. Differential diagnoses

need to be considered. The student needs to be able to understand and verbalize

to the patient and preceptor the indications, contraindications and potential

complications of each OMM procedure in each clinical scenario. The student

must also learn how to treat any complications or adverse reactions that may

occur in response to an OMM treatment. Lastly, each student should be able to

describe the OMT procedure accurately to both the patient and the preceptor.

Documentation of findings from the osteopathic structural evaluation and

response to OMT are essential components that should be mastered in order to aid

the student in developing a successful practice.

Emotional maturity affects the student’s ability to concentrate and focus

on what they are feeling with their palpating hands. Many students have limited

life experiences as they have been in the protected environment of school much of

their lives. They will often encounter patients who are more savvy, scarred and

experienced, and who have more stressors than the student can imagine. This can

overwhelm the student who is not so experienced. The preceptor needs to be

sensitive and aware of each student’s capabilities in terms of emotional maturity.

Help each student understand and make emotional adjustments as necessary to

each patient’s situation. This will help the student maintain focus and

concentration. Additionally, some patients may be attractive or repulsive to the

student. This can cause confusion and interfere with their concentration on

palpatory findings. Enabling the student to focus and passionately engage in the

healing process will enhance the student’s OMM effectiveness.


Year OMM Rotation 10

There are ten basic steps in teaching a procedural skill like OMT. They are:

1. Prepare the student

2. Demonstrate the procedure

3. Assess student’s cognitive understanding

4. Allow the student to practice the procedure

5. Observe student’s performance

6. Provide prompt, general feedback

7. Encourage self-assessment

8. Increase complexity of the problem

9. Modify approach to a problem

10. Provide prompt, detailed feedback of student’s performance

Let’s elaborate upon and discuss each of these steps.

Preparing the student means to state clearly the objectives of your

evaluation process. In other words, make it clear to the student what you are going

to be evaluating. Tell the student what behaviors you are going to be measuring

to determine quality of performance. For example, you may state that you are

going to evaluate, by observation, palpating and listening, how accurate he or she

is in finding and naming a segmental somatic dysfunction. Next you need to

assess how well is the student prepared for the tasks you are about to ask him or

her to perform. Assess the student’s current knowledge, skill level, ability and

motivation. This will enable you to tailor your lessons appropriately and also be

able to assess the student’s progress over the course of the rotation.

Demonstrate the OMT procedure you would like the student to learn. First

describe it, present simplified rules and be sure the student sees the whole

procedure. Attend to different aspects of the procedure, including the difficult

parts. Make the demonstration short; include only the essentials. Show possible

errors. Tell the student at and for what he or she is to observe. Limit discussion

about details until later.

Next have the student give you a brief verbal description of the procedure,

its indications, contraindications and precautions. Be sure to notice and correct

inaccurate usage of terms and concepts. You may want to use the Foundations for

Osteopathic Medicine textbook and the Glossary of Osteopathic Terminology for

reference.

Many of the students have not practiced OMT on real patients. Usually a

preceptor can find a group of patients willing to let students learn on them. Some

preceptors have these patients come in to see the student primarily and help the

preceptor educate and train the students for a reduced or no office charge. Try to

allow each student time to practice and develop confidence.

It is important to observe the student perform OMT on patients at least in

the beginning of the rotation. Not only is this important for patient safety, but also

for assessing the level of the student’s ability and his or her strengths and

weaknesses. Observing at least once weekly thereafter will help assess the

student’s progress and provide timely feedback throughout the rotation.

Although it may be tempting to give detailed feedback, it is better to give

general feedback initially. Identify positive behaviors and point out areas that, in

general, need improvement. Provide feedback as soon as is possible after an

OMT procedure is done. Patients will help with assessing how well the student is

doing and often will tell the student directly, but sometimes will tell the preceptor



and not the student. In this latter situation, take a few seconds to privately relay to

the student the feedback from the patient. Before telling the student what the

patient or you think, you may want to ask the student to self-assess his or her

performance. Some questions the student should be asking are:

1. Did I know what I was doing and why?

2. What were my findings?

3. How did they relate to the patient’s condition?

4. Did I reassess the findings to see if they changed after the procedure?

5. Did I assess the patient’s comfort level and understanding of my

diagnosis and explanations?

6. How well did the patient tolerate or appreciate my treatment?

7. Were there any adverse reactions?

Once you are assured that the student understands basic problem solving

using osteopathic palpatory procedures and OMT, provide opportunities for the

student to diagnose and treat more complex patients. See if he or she can apply

the same philosophy and principles learned in the simpler cases. Some students

may be able to handle complex patients in the first week, others after the second

week. An example of a simple case would be an uncomplicated musculoskeletal

problem amenable to OMT. An example of a complex case would be a patient

with co-morbidities and the musculoskeletal component is secondary, as in

viscero-somatic reflexes in a patient with liver or renal failure. Some patients may

be on an anticoagulant, or have severe rheumatoid arthritis, so use of some direct

action OMT may be contraindicated. Patients who are paraplegic, morbidly obese

or cannot lie down, or on the other hand cannot sit up, are also challenging for

students as well as for physicians.

With the challenging or complex patient, adaptation of OMT skills to fit

the situation is necessary. Most students need help with knowing what is safe and

effective and how to modulate techniques as needed for each patient. Afterwards,

prompt feedback will go a long way towards engendering self-confidence in the

application of Osteopathic Principles and Practices in any clinical situation.

Finally, it may be helpful if you would consider the following assessments

in evaluating and providing feedback to students during the rotation. Ask yourself

if the student demonstrates any of the following:

Hesitation

Tentative or poor contact

Inaccurate Verbalization

Inappropriate patient position

Inappropriate student position

Lack of control or balance

Lack of localization

Lack of concentration

Inappropriate or wrong diagnosis

Inappropriate or wrong treatment

Dangerous maneuver

Poor efficacy or other inefficiency

Rough handling



Addressing these common shortcomings at the beginning of the rotation will help

the student to focus on specific behaviors that require improvement before the end

of the rotation.



OMT Competency Evaluation Checklist

Student Name and Level of Education___________________________

Observed Behaviors Completed Not

completed

Comments

Presented the patient’s history,

physical examination findings, and

other diagnostic findings.

Explained the basic anatomic and

pathophysiologic bases for the

patient’s disease, including an

osteopathic structural perspective.

Listed goals of treatment.

Performed an osteopathic

structural examination.

Determined significant areas of

somatic dysfunction.

Prepared a treatment plan that

included the consideration of

contraindications.

Demonstrated the appropriate use

of osteopathic manipulative

techniques for the patient.

Documented treatment and any

immediately observable effects.

Designed a comprehensive

osteopathic management plan.

______________________________ __________________________

Physician Preceptor Printed Name Physician Preceptor Signature

Date of Evaluation _________



Coding for Osteopathic Manipulative Procedures

Updated by AOA, August 1999

There are three coding classification systems currently required by third party

payors for reimbursement. These are:

1. ICD-9 CM: The International Classification of Diseases: 9th Revision; Clinical

Modification.

2. HCPCS: HCFA Common Procedural Coding System

3. CPT: Physicians' Current Procedural Terminology

With these coding systems, there is terminology of particular relevance to

osteopathic medicine.

The term somatic dysfunction is used to designate 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.

The term can be further amplified to denote the specific dysfunction (e.g.,

myositis, neuralgia, limited arthrodial motion) and/or associated visceral

pathology (e.g., colitis, pneumonitis).

Example: Lumbar and sacral somatic dysfunction with lumbar myositis and right

sciatic neuralgia.

The term osteopathic manipulative treatment is defined as a form of manual

treatment applied by a physician to eliminate or alleviate somatic dysfunction and

related disorders. As this treatment can be accomplished by a variety of

techniques, one can amplify this terminology to indicate the specific technique

employed (e.g. counterstrain, myofascial release) and the specific body region(s)

treated.

ICD-9-CM

This classification system is used to report the diagnosis. The publication itself

has three parts:

Volume I: Tabular list: Numeric, up to 5 digits for some diagnoses

739 - Nonallopathic lesions, not elsewhere classified

Includes: segmental dysfunction and somatic dysfunction

In addition, there are specific fourth digits used to denote the specific body

region involved.

Example: 739.3 Lumbar region lumbosacral

Volume 2: Index to Diseases: Alphabetic by presenting symptom or disease

Example: Dysfunction somatic (Various regions listed with appropriate

numbers)

Volume 3: Procedures: Used for inpatient only.



93.6 Osteopathic manipulative treatment

Specific techniques employed denoted by fourth digit.

Example: 93.62 Osteopathic manipulative treatment using high velocity,

high amplitude forces; Springing forces

Physicians' Current Procedural Terminology (CPT)

Physicians to report services and procedures use this 5-digit classification system.

In 1994, the CPT Editorial Panel voted to accept the proposal of the AOA to

move the osteopathic manipulative treatment codes from the HCPCS

alphanumeric system into CPT. The CPT publication includes a definition of

OMT as well as definitions of specific body regions. The OMT codes (98925-

98929) are structured by the number of body regions treated, not the body site or

the technique(s) employed. These codes should be used for both inpatient and

outpatient treatment.

Example: 98925 Osteopathic manipulative treatment (OMT); one to two

body regions involved

The AOA has a publication, OMT Coding Instructional Manual available for

purchase. To order, please contact the AOA's Order Department.

In addition, there are two-digit modifiers that may be attached to the 5-digit

procedure code to indicate that a service or procedure that has been performed has

been altered in some way from the code descriptor.

NOTE: For Medicare, the -25 modifier must be attached to the E/M code reported

in conjunction with OMT.

In 1992, the entire coding system for evaluation and management (E/M) was

changed. The new E/M codes range from 99201 to 99499 and are organized

according to site of service, new vs. established patient and the level of care

provided. The appropriate code to report is based on key components: history;

examination; medical decision making; counseling; coordination of care; nature

of presenting problem; and time. The first three components (history, examination

and medical decision making) are considered the key components in selecting a

level of E/M service.

Medicare RBRVS (Resource Based Relative Value System):

A physician payment schedule initiated in January 1, 1992. The RBRVS

represents the first major change in how Medicare pays for physicians' services

since Medicare's inception in 1965. The major components of the RBRVS are:

The relative value scale;

The conversion factor;

Geographic adjustments; and

Balance billing limitations



Effective January 2000, Practice Expense Relative Value units will be assigned

for each CPT code. These values will assist in differentiating the true physician

expenses that are related to the code based on site specific settings (ie. facility vs.

non-facility) as well as the expenses related to Specialty specific expenses (i.e.

primary care vs. proceduralist).

HCFA 1500 Form:

A universal billing form developed by HCFA for physicians and other providers

to report services. This form was revised in 1992 to meet new government

mandates for Medicare reimbursement. These forms are available through the

AOA at a special member discount.

Appropriate Use of OMT Codes

After the physician evaluates the patient and arrives at a diagnosis, it is allowable

to use an evaluation and management (E/M) code in addition to the appropriate

OMT code (98925-98929) provided the physician has documented in the patient's

record the E/M service provided. It is important that the E/M service is

appropriately documented as well as the OMT service provided. However,

separate diagnoses are not required for the separate services.

Coding Case Study

A 42-year old male with confusion and pain in the neck and upper back presents

to a neurosurgeon. Patient also complains of exacerbation of previous lumbar disc

herniation with radiculitis following a motorcycle accident. After evaluation of

the patient, the diagnosis is 1) closed head injury and 2)somatic dysfunction of the

head, cervical, lumbar, sacral and rib region. The physician then utilizes

osteopathic manipulative treatment to treat the patient's head, cervical, lumbar,

sacral and rib regions.

Diagnosis Coding:

1) Somatic dysfunction, head 739.0

2) Somatic dysfunction, cervical 739.1

3) Somatic dysfunction, lumbar 739.3

4) Somatic dysfunction, sacral 739.4

5) Somatic dysfunction, rib 739.8

Procedure Coding:

1) Osteopathic manipulative treatment (OMT): five to seven body regions

involved 98927

2) Office or other outpatient visits for the evaluation and management of an

established patient, which requires at least two of these three key components:

- a detailed history

- a detailed examination

- medical decision making of moderate complexity

- 99214-25

Explanation of Code Selection:



For the diagnosis coding of somatic dysfunction it is necessary to code to the

fourth digit (e.g., 739.1) as one should code to the most specific ICD-9 code. Not

coding to the fourth digit could cause the payor to reject this claim.

Code 98927 was selected for the OMT provided as five regions were treated. In

selecting the E/M code, since the physician had seen the patient within the past

three years, this was an established patient. A detailed history and examination

were performed and medical decision making of moderate complexity was

provided hence the selection of CPT code 99214. The -25 modifier was added as

this indicates to the payor that a significant, separate identifiable evaluation and

management service was provided in addition to the OMT.

Reviewing the Explanation of Benefits (EOB)

Review the Explanation of Benefits (EOB) provided by the payor. This will

indicate what you billed and how the claims processor recorded it. Sometimes

errors are made by the claims processor in entering data, so this could be one

reason for rejection. Make sure you have attached the -25 modifier to the E/M

code reported as not doing this will flag the E/M service for nonpayment. Be sure

that the patient has met all insurance deductibles and copayments. Also be sure

that osteopathic manipulative treatment is covered under the patient's policy. A

patient's insurance information should be updated each time the physician sees

that patient to ensure that the patient has not changed payors or type of coverage.

Claims Appeal

When you are sure that all of the above conditions have been satisfied and

you feel that an error has been made in processing, you need to send an appeal

letter to the payor. The letter should include the claim number which is listed on

the EOB, the patient's identification number, the provider (physician)

identification number and an explanation from the physician as to why (s)he is

appealing this claim. Complete documentation should be attached, including a

copy of the original claim filed as well as the EOB. If possible, you should

address your appeal to a specific individual at the payor such as the carrier

medical director or claims manager. The claims processor who processed the

original claim will have little or no authority to adjust the claim.



Management Plan Including OMT

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General Goals of Manipulative Medicine Treatment:

1. Improve motion

2. Improve circulation, venous and lymphatic drainage (fluid flow)

3. Improve visceral response to stress and medications

4. Decrease pain

5. Make patient feel better

Goals of Treatment Utilizing Osteopathic Manipulation

1. Improve posture and body movement

2. Mobilize fluids to and from tissues

3. Calm down hyper-active nerves

4. Enhance homeostatic mechanisms:

Maximize Immune and Endocrine functions to

Decrease reliance on medications

Facilitate reliance on good nutrition and exercise

Alleviate pain, anxiety & discomfort

Console Motivate Educate

Which patients should be treated with osteopathic manipulative medicine? 1. Patients with a diagnosis of Somatic Dysfunction

2. Patients with evidence of congestion

3. Patients with painful conditions

Dosage Guidelines

1. The sicker the patient, the less the dose

2. Allow 3-7 days for the patient to respond

3. The younger the patient, the more rapid the response

4. Acute cases require smaller more frequent doses at first

Frequency of Treatment Ambulatory patient with a primary musculoskeletal problem

Acute - once or twice weekly

Chronic - once or twice monthly



Re-evaluate before and after each treatment

If no improvement from treatment to treatment, re-evaluate diagnosis

Duration of Treatment

1. Acute - until normal function is restored or condition is returned to baseline

(plateau)

2. If unable to effect continued improvement - reassess and adjust

management plan

3. Chronic - determined by nature of condition, patient response and needs

Side effects

1. Soreness

2. Shifting myalgias

3. Irritability

4. Usually resolve by 3 days post treatment

Adverse Effects

1. Document any adverse effects of OMT procedures

2. Report any incidence of disability or death from any OMM procedure

Maintenance and Prevention

1. Provide education, including proper biomechanics and ergonomics, and

exercises

2. Stretch office visits out gradually over time depending on progressive

improvement

3. Ensure comprehensive medical care is provided in addition to OMM

Methods of Treatment

1. Choose Direct vs. Indirect vs. Combined

2. Use appropriate OMT according to patient’s condition, considering

indications, contraindications and precautions

3. Consider student’s abilities and morphology as well as the patient’s

morphology and co-morbidities

4. Enable students to utilize procedures which they have practiced and feel

confident in using in addition to introducing them to effective ones used in

your practice



Sample OMM Procedure Note

Student Name_____________________________

Date____________

Patient initials___________

Chief Complaint_____________________________________________________

Diagnoses__________________________________________________________

___________________________________________________________________

___________________________________________________________________

Informed Consent given including indications, contraindications, possible complications and

alternate forms of treatment available, if any, for the condition. Yes No

OMT used: Direct Indirect Combined

HVLA MET SCS CS MFR FPR ART Other

Results of OMT:

1. Unchanged______

2. Improved_______

3. Resolved_______

4. Adverse Reaction ___________________________________________________

_____________________________________________________

_____________________________________________________

SOAP note completed: Yes No

Preceptor Name ________________________________

Preceptor Signature _____________________________



Sample Procedure checklist form for OMM rotation:

Name___________________________________________

Rotation Location ____________________Dates____________

Procedures Date/Initial

Took a complete history

Performed a complete

musculoskeletal structural

exam

Identified regional and

segmental somatic

dysfunctions based on

T.A.R.T. changes

Documented findings in

the medical record in the

form of a SOAP Progress

Note

Verbalized indications,

contraindication and

precautions if any

Treated somatic

dysfunction with OMT

Noted response to

treatment, including

improvement, no change,

worsening of signs or

symptoms, adverse

reactions and

complications



Required Case Presentation

Students are required to complete one case-based presentation including

an in depth discussion of one or more aspects of the case (e.g. a presenting

symptom or sign, a diagnostic category or management issue) that they want to

learn more about during the rotation. The actual case chosen should be based

on a patient they personally evaluated. The presentation will be delivered

orally and written to you, the OMM Preceptor, at or near the end of the rotation.

The presentation should be about 15-20 minutes in length and should be

accompanied by handouts including a written description of the case and an

evidence based discussion of the topic to be presented with a list of the recent

literature used to obtain information for the discussion. The literature could

include material from journal articles, national guidelines, professional

publications like the Journal of the AAO, found on the web site of the American

Academy of Osteopathy at www.academyofosteopathy.org, or the JAOA, now

available on the AOA website, www.do-online.org. Also see the American

Association of Colleges of Osteopathic Medicine web site at www.aacom.org, or

recent textbooks, such as FOM 2nd

edition, 2003. The OSTMED database can be

accessed for osteopathic literature not cited in other more general databases.

Suggested topics for case presentation and discussion are listed below:

Suggested Topics for Case Based Presentation

Somatic Dysfunction as it relates to a patient with any of the following

conditions:

Whiplash

Rheumatological conditions, i.e., fibromyalgia, osteoarthritis

Respiratory Difficulties, i.e., cough, dyspnea

Orthopedic or sports injuries

Neurologic problems, i.e., learning disabilities, nerve entrapments

Neck pain

Metabolic disorders, i.e., diabetes, thyroid disease

Low back pain

Infectious Diseases, i.e., pneumonia, URI, sinusitis

Head trauma

Fatigue and Weakness

Cardiovascular disorders, i.e., hypertension, coronary artery disease, CHF

Behavioral problems, i.e., drug, tobacco or alcohol abuse/chemical dependency,

depression, anxiety, social environment

Students are to send a copy of their presentation to the OMM dept., care of Dr.

Seffinger, or email to [email protected] for use in curriculum

development. Students who are interested in publishing their case presentation

can request assistance from Dr. Seffinger. Examples of published OMM case

reports can be found online at www.academyofosteopathy.org and click on the

http://www.do-online.org/

http://www.aacom.org/

mailto:[email protected]

http://www.academyofosteopathy.org/



link to publications and then Journal of the AAO. Click on any journal icon and

look up the table of contents for the case report published in each issue.

Required Readings During Junior Year OMM Rotation Topic Chapter(s) in

Ward, FOM

Pages in

Kuchera,

Systemic

Dysfunction

1 Philosophy 1 iv-vi

2 History 2

3 Health Promotion and Maintenance 13

4 Pain Management 15

5 Life Phases and Health 16

6 Stress Management in Primary Care 17

7 Clinical Problem Solving 19

8 Osteopathic Considerations in Family Practice and Primary

Care

20-23 1-232

9 Osteopathic Considerations in the Clinical Specialties 24-37

10 Osteopathic Considerations in Palpatory Diagnosis and

Manipulative Treatment

38-73

Seffinger MA, Hruby RJ. Evidence Based Manual Medicine: A Problem

Oriented Approach. Saunders/Elsevier, 2007.

Nelson KE, Glonek T, eds. Somatic Dysfunction in Osteopathic Family Medicine.

Philadelphia: LWW. 2006.

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