OMT Reimbursement Rates: CPT Codes 98925-98929 Guide

Key Takeaways

Medicare OMT reimbursement decreased 23.2% between 2000-2019

CPT codes 98925-98929 valued by body regions treated

Somatic dysfunction documentation required for coverage

E/M services billed separately with Modifier 25

Osteopathic manipulative treatment reimbursement rates have declined significantly over two decades while documentation requirements have grown stricter. Between 2000 and 2019, adjusted sum reimbursement for OMT dropped 23.2% according to research published in the Journal of Osteopathic Medicine. Osteopathic physicians now face lower payment rates alongside increased claim denials driven by insufficient somatic dysfunction documentation and overlap disputes between evaluation codes and manipulation services.

Billing osteopathic manipulation correctly requires understanding how Medicare values each CPT code based on body regions treated, when payers allow separate E/M charges, and which documentation elements prevent denials. This guide covers Medicare Physician Fee Schedule rates for codes 98925 through 98929, state Medicaid variation, private insurance coverage patterns, and the appeal strategies osteopathic practices use when claims are rejected.

Understanding OMT CPT Codes and Reimbursement Structure

The American Medical Association assigns five CPT codes to osteopathic manipulative treatment based on the number of body regions addressed during a single encounter. Each code carries a distinct Relative Value Unit (RVU) that Medicare and most commercial payers use to calculate reimbursement. The Centers for Medicare & Medicaid Services defines body regions as head, cervical spine, thoracic spine, lumbar spine, sacral spine, pelvis, lower extremities, upper extremities, rib cage, and abdomen. A physician treating three distinct regions would bill CPT 98927 rather than performing three separate one-region treatments coded as 98925.

Medicare calculates payment by multiplying the work RVU, practice expense RVU, and malpractice RVU for each code by the geographic practice cost index, then applying the annual conversion factor. For 2024, the conversion factor stands at $33.0775 per RVU. Private insurers typically follow Medicare’s valuation framework but may adjust rates based on contract negotiations. According to the American Osteopathic Association, commercial payers reimburse osteopathic manipulation at rates ranging from 80% to 140% of Medicare rates depending on network status and regional market dynamics.

Research tracking two decades of Medicare claims reveals a shift toward higher body region codes. Between 2000 and 2019, utilisation of CPT 98928 and 98929 increased while single-region and two-region treatments declined. This pattern suggests osteopathic physicians are documenting more comprehensive manipulative interventions, though total adjusted sum reimbursement decreased during the same period. The decline reflects both downward pressure on RVU values and stricter coverage limitations applied by Medicare Administrative Contractors.

Medicare and Medicaid OMT Reimbursement Rates by CPT Code

Medicare reimburses osteopathic manipulative treatment through the Physician Fee Schedule using national and locality-adjusted rates. The following CPT codes represent the complete range of OMT services recognised for payment, with reimbursement varying by geographic region and whether the physician practises in a facility or non-facility setting. Claims management software can help osteopathic practices track regional rate differences and identify underpayment patterns across payer contracts.

OMT Reimbursement Rates CPT Code 98925: One to Two Body Regions

CPT 98925 covers osteopathic manipulation of one or two body regions during a single encounter. Medicare assigns this code .82 work RVUs, 0.73 practice expense RVUs for non-facility settings, and 0.05 malpractice RVUs. Using the 2024 conversion factor, the national average non-facility rate equals $52.97. Geographic adjustments push this figure higher in urban markets with elevated practice costs and lower in rural areas. Medicaid programs in states like California and New York typically reimburse at 60-75% of Medicare rates for this code, while Texas Medicaid has historically limited coverage to specific somatic dysfunction diagnoses approved through prior authorisation.

OMT Reimbursement Rates CPT Code 98926: Three to Four Body Regions

CPT 98926 applies when an osteopathic physician manipulates three or four body regions. This code carries 1.24 work RVUs, 1.09 practice expense RVUs for non-facility settings, and 0.07 malpractice RVUs, yielding a national average non-facility rate of $79.39 under 2024 Medicare rates. Commercial payers often bundle this code with evaluation services when both occur during the same visit, requiring physicians to append Modifier 25 to the E/M code and provide documentation proving the evaluation was separately identifiable. Practices that treat conditions like chronic low back pain or cervicogenic headache frequently bill this code when addressing the lumbar spine, cervical spine, and associated muscle groups in one session.

OMT Reimbursement Rates CPT Code 98927: Five to Six Body Regions

CPT 98927 reflects treatment of five to six body regions and represents one of the most commonly billed osteopathic manipulation codes according to Medicare claims data. The code is valued at 1.66 work RVUs, 1.46 practice expense RVUs for non-facility settings, and 0.09 malpractice RVUs, translating to a national average non-facility rate of $106.14. Osteopathic physicians treating patients with systemic somatic dysfunction patterns-such as those resulting from postural imbalances or compensatory mechanisms following injury-regularly document involvement of the cervical spine, thoracic spine, lumbar spine, sacral spine, pelvis, and rib cage within a single treatment encounter. Medicare Administrative Contractors scrutinise claims for this code when visits lack documentation of distinct manipulative techniques applied to each region.

OMT Reimbursement Rates CPT Code 98928: Seven to Eight Body Regions

CPT 98928 covers osteopathic manipulation of seven to eight body regions. This code carries 2.08 work RVUs, 1.82 practice expense RVUs for non-facility settings, and 0.12 malpractice RVUs, resulting in a national average non-facility rate of $132.89. The code sees increased utilisation in practices treating complex musculoskeletal conditions requiring comprehensive manipulation from head to pelvis. According to utilisation trends, this code shifted from representing 12% of OMT claims in 2000 to 19% by 2019, suggesting growing recognition of the clinical value in addressing multiple body regions during acute care episodes. Osteopathy practice software with built-in body region tracking helps physicians document the specific regions manipulated during each encounter, reducing the risk of downcoding when payers review claims.

OMT Reimbursement Rates CPT Code 98929: Nine to Ten Body Regions

CPT 98929 represents the most comprehensive osteopathic manipulation service, covering nine to ten body regions in one visit. Medicare assigns this code 2.50 work RVUs, 2.18 practice expense RVUs for non-facility settings, and 0.14 malpractice RVUs, translating to a national average non-facility rate of $159.31. Claims for this code require detailed documentation of somatic dysfunction findings in nearly all body regions and the specific osteopathic techniques applied to each. Payers frequently request medical records when this code appears repeatedly for the same patient, as they assess whether the intensity of treatment aligns with documented medical necessity. Practices that specialise in treating patients with systemic conditions like fibromyalgia or widespread myofascial pain syndrome use this code when their treatment plan addresses dysfunction across the entire axial and appendicular skeleton.

Documentation Requirements for OMT Reimbursement

Medicare requires documentation of somatic dysfunction in each body region treated with osteopathic manipulation. Somatic dysfunction means impaired or altered function of related components of the somatic system including skeletal, arthrodial, and myofascial structures, along with related vascular, lymphatic, and neural elements. The American Academy of Family Physicians notes that evaluation of OMT patients typically requires more than five minutes of assessment time before manipulation begins, as physicians must document tissue texture changes, asymmetry, restriction of motion, and tenderness across multiple body regions.

Each manipulated body region needs a clinical justification linking the documented dysfunction to the patient’s presenting complaint. A claim for CPT 98927 covering six body regions must show findings in all six areas-such as “cervical spine: tissue texture changes with restricted right rotation, tenderness at C4-C5; thoracic spine: asymmetry with left lateral deviation T6-T8, restricted extension.” Generic statements like “multiple areas of dysfunction noted” or “full body treatment performed” do not meet coverage criteria. Payers deny claims when documentation fails to specify which osteopathic techniques the physician applied to address each region’s dysfunction.

When billing evaluation and management services on the same date as OMT, physicians must document that the E/M service was separately identifiable from the pre-manipulation assessment. This requires showing that the evaluation addressed diagnostic or treatment planning decisions beyond determining which body regions to manipulate. For instance, a physician who evaluates a patient’s medication regimen, orders diagnostic studies, and discusses surgical consultation options before performing OMT can bill both services. A physician who only examines areas of somatic dysfunction before manipulation cannot, as that assessment is inherent to the manipulation service. Digital forms that prompt physicians to document separate E/M elements help reduce denials resulting from insufficient differentiation between evaluation and manipulation components.

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Billing E/M Services with Osteopathic Manipulation

Osteopathic physicians can bill evaluation and management codes alongside OMT when the E/M service is significant and separately identifiable from the pre-manipulation assessment. This requires appending Modifier 25 to the E/M code, which signals to payers that the physician performed a distinct diagnostic or management service on the same date as a procedure. According to American Osteopathic Association guidance, payers deny E/M charges with OMT more frequently than any other osteopathic billing scenario, as many consider the initial evaluation inherent to selecting manipulation techniques and body regions.

Medicare’s position allows separate E/M billing when documentation shows the physician addressed problems beyond those requiring manipulation. A new patient visit where the physician takes a comprehensive history, performs a complete physical examination, reviews prior records, orders laboratory tests, and then applies OMT to treat identified somatic dysfunction qualifies for both E/M and manipulation codes. An established patient visit where the physician only assesses areas of musculoskeletal complaint before manipulating does not. The distinction turns on whether the evaluation influenced diagnostic or treatment decisions independent of the manipulation plan.

Private payers apply varying standards for E/M bundling with manipulation services. Some require prior authorisation before allowing both codes on the same claim. Others automatically bundle lower-level E/M codes (99212, 99213) with manipulation but allow higher-level codes (99214, 99215) to be billed separately when medical necessity supports the complexity. Practices that frequently bill E/M with OMT should audit their denial patterns by payer to identify which insurers consistently reject the combination and adjust billing protocols accordingly. Physical therapy EMR systems face similar bundling challenges when billing evaluation codes with therapeutic procedures, making cross-specialty documentation standards useful for osteopathic practices.

Time-based documentation strengthens E/M claims billed with OMT. When the physician spends significant time on diagnostic reasoning, care coordination, or patient counselling separate from manipulation, documenting total visit time and the time spent on non-manipulation activities helps justify both services. For example, “Total visit time 45 minutes. Spent 25 minutes reviewing patient’s MRI results, discussing surgical versus conservative treatment options, and coordinating referral to pain management specialist. Remaining 20 minutes spent performing OMT to address acute somatic dysfunction.” This documentation pattern separates the evaluation from the manipulation and shows the E/M service dominated the encounter.

Common OMT Claim Denials and Appeal Strategies

Insufficient somatic dysfunction documentation triggers the majority of OMT claim denials. Payers reject claims when medical records lack specific findings for each manipulated body region or when physicians describe dysfunction in vague terms. A claim stating “patient presents with back pain, OMT performed to lumbar and thoracic regions” will be denied for failing to document tissue texture changes, asymmetry, restriction of motion, or tenderness. Successful appeals require submitting detailed notes showing objective findings in each region, such as “lumbar spine: paraspinal muscle hypertonicity L3-L5 bilaterally, restricted flexion to 60 degrees, tenderness to palpation over L4 spinous process.”

Payers also deny OMT claims when manipulation appears duplicative of physical therapy services the patient receives from another provider. Medicare’s global surgical period concept extends to manipulation-if a patient underwent spinal surgery and receives post-operative OMT from the surgeon, those services may be bundled into the surgical fee. Similarly, when a patient sees both an osteopathic physician and a physical therapist for the same condition, commercial payers sometimes apply frequency limitations or require documentation showing the services address different aspects of the condition. Appeals should demonstrate that osteopathic manipulation targets somatic dysfunction while physical therapy focuses on strengthening, range of motion, or functional training.

Denials based on medical necessity frequently cite lack of measurable improvement over multiple treatment sessions. When a patient receives OMT weekly for months without documented functional gains, payers question whether continued treatment meets coverage criteria. Appeals must show objective measures like pain scale scores, range of motion measurements, or activity limitations improving over the treatment course. Practices that track outcomes using practice management software can generate reports demonstrating patient progress, which strengthens medical necessity arguments during appeals.

Timely filing represents a procedural denial category distinct from clinical denials. Most payers require OMT claims within 90 to 180 days of the service date. When practices batch-bill at month-end or quarter-end, claims for services performed early in the period risk exceeding filing deadlines if the batch is delayed. Some Medicare Administrative Contractors have reduced filing windows to 90 days for manipulation services specifically, making prompt claim submission essential. Automated workflows that submit claims within 48 hours of service completion eliminate most timely filing denials.

Private Insurance Coverage and Contract Negotiation

Commercial health plans determine OMT coverage through medical policy bulletins that may differ from Medicare’s criteria. Some insurers classify osteopathic manipulation as alternative medicine subject to visit limits, prior authorisation, or network restrictions. Others treat it as conventional musculoskeletal care with coverage equivalent to physical therapy or chiropractic services. The variability means practices must verify coverage before rendering services and educate patients about potential out-of-pocket costs when their plan imposes restrictions Medicare does not apply.

Network participation agreements negotiated between practices and commercial payers establish reimbursement rates for OMT services. These rates typically reference Medicare as a baseline-“120% of Medicare” or “150% of Medicare”-though exact figures depend on regional market dynamics and the practice’s negotiating leverage. Practices in areas with few osteopathic physicians can command higher rates than practices in saturated markets. When negotiating contracts, emphasising outcome data showing reduced imaging utilisation, decreased opioid prescribing, or improved patient satisfaction scores may justify rates above standard commercial levels.

Value-based payment models emerging in commercial insurance create opportunities for osteopathic practices to demonstrate clinical and financial benefits of manipulation. When a practice participates in an accountable care organisation or bundled payment arrangement, showing that OMT reduces downstream costs-such as emergency department visits or surgical procedures for musculoskeletal conditions-supports both clinical validation and contract negotiation. According to health policy research, manual therapies including osteopathic manipulation may reduce healthcare spending for chronic back pain patients compared to pharmaceutical-focused treatment approaches, though more large-scale studies are needed to quantify the effect consistently across populations.

State Medicaid programs apply highly variable coverage policies for osteopathic manipulation. Some states reimburse all five CPT codes without restriction. Others limit coverage to specific diagnoses, require prior authorisation, or cap annual visits. For example, several state Medicaid programs restrict OMT to patients with acute conditions and deny coverage for chronic musculoskeletal diagnoses unless the patient has failed other conservative treatments first. Practices serving Medicaid populations should review their state’s provider manual annually, as coverage policies change during budget cycles. HIPAA-compliant clinic software that tracks payer-specific billing rules helps staff apply the correct coverage criteria before submitting claims.

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Conclusion

Osteopathic manipulative treatment reimbursement rates reflect a complex intersection of coding accuracy, documentation quality, and payer-specific coverage policies. The 23.2% decline in adjusted sum reimbursement over two decades occurred alongside stricter somatic dysfunction documentation requirements and increased bundling of evaluation services with manipulation. Osteopathic physicians who understand how Medicare values CPT codes 98925 through 98929, when payers allow separate E/M charges with Modifier 25, and which documentation elements prevent denials position their practices to maximise legitimate reimbursement while avoiding compliance risks.

Successful OMT billing requires structured documentation showing objective findings in each manipulated body region, clear differentiation between evaluation and manipulation components when billing both services, and tracking of denial patterns to identify systemic issues before they trigger audits. As commercial payers and state Medicaid programs apply varying coverage policies, practices must verify patient-specific benefits before rendering services and educate patients about potential out-of-pocket costs. The shift toward value-based payment models creates opportunities for osteopathic practices to demonstrate clinical outcomes justifying competitive reimbursement rates in contract negotiations.

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