CPT code 98926 – Osteopathic manipulative treatment, 3-4 body regions

Key takeaways

CPT code 98926 covers osteopathic manipulative treatment (OMT) of three or four of the 10 recognized body regions in one encounter.

DOs, and MDs trained in OMT, can bill it, while chiropractors and physical therapists cannot, per CMS LCD L33616.

Each treated region must be named in the note with its own technique, or the note cannot support the code level.

Modifier AT is a chiropractic Medicare requirement and does not belong on an OMT claim.

RVUs and Medicare rates for 98926 change every year and by locality, so check the CMS fee schedule before quoting a figure.

What is CPT code 98926?

CPT code 98926 is the American Medical Association procedure code for osteopathic manipulative treatment (OMT) of three or four body regions in one encounter. The official descriptor reads: Osteopathic manipulative treatment (OMT); 3-4 body regions involved.

It is billed by doctors of osteopathic medicine (DOs), or by MDs trained in OMT. Chiropractors and physical therapists are still excluded, per CMS LCD L33616.

OMT is a hands-on approach in which the physician diagnoses somatic dysfunction and treats it with manipulative techniques. Common ones include high-velocity low-amplitude (HVLA) thrust, myofascial release (MFR), counterstrain, and muscle energy technique.

How 98926 compares with the other OMT codes

The five OMT codes differ only by the number of body regions treated. All five sit in the 98925-98929 OMT subsection of the medicine section of the CPT codes set. Picking the wrong tier is a common trigger for OMT upcoding audits, so the region count in the note must match the code billed.

The region count reflects the regions treated and documented, not the number examined or assessed. Auditors look for a technique recorded against each region, not a count ticked in a checkbox field.

What counts as a body region for CPT code 98926?

CPT recognizes 10 body regions for OMT coding. To bill 98926, the physician must treat and document three or four of them in a single encounter.

• Head
• Cervical region
• Thoracic region
• Lumbar region
• Sacral region
• Pelvic region
• Lower extremities (both legs count as one region)
• Upper extremities (both arms count as one region)
• Rib cage
• Abdomen and viscera

The upcoding trap: sub-areas within one region do not count as separate regions. Treating the right and left lower extremities is one region, not two. Treating L1-L3 and L4-L5 is still the lumbar region. Count the distinct regions first, then read the code off the grid below.

Medical necessity must support treating that many regions. Picture a patient with isolated low back pain whose visit is billed at 98926. That claim will draw scrutiny unless the note explains why three or four regions needed treatment that day.

ICD-10 codes commonly paired with CPT 98926

The paired diagnosis code must support medical necessity for OMT. Payers cross-reference the ICD-10 code against the CPT code to confirm the treatment is clinically appropriate. These are the diagnoses most often used with CPT code 98926.

M99 somatic dysfunction codes are the strongest medical necessity support for OMT. Spinal cases often lead with M99.01 for the cervical region or M99.03 for the lumbar region. Some payers reject OMT claims where the only diagnosis is a non-specific pain code with no matching M99 code. Listing both improves claim acceptance.

Documentation requirements for CPT code 98926

Insufficient documentation is a leading cause of CPT 98926 denials. Each of the three or four treated regions must appear by name in the note, with the technique used on it. A checkbox form that records a region count without naming each region is not enough.

A compliant OMT note for 98926 includes these elements, in line with CMS LCD L33616 and AOA coding guidance:

1. Chief complaint: the patient’s presenting problem in their own words.
2. History of presenting illness: onset, location, duration, quality, and modifying factors.
3. Osteopathic structural exam findings: TART findings (tissue texture, asymmetry, restriction of motion, tenderness) documented per region.
4. Regions treated: each of the three or four regions named explicitly, such as “cervical, thoracic, lumbar, and sacral regions treated.”
5. Technique per region: the manipulative technique used in each region, such as HVLA, MFR, counterstrain, or muscle energy.
6. Patient response: the immediate response to treatment, including changes in range of motion and pain level.
7. Assessment and plan: diagnosis codes, next visit timeline, and home exercise guidance.

Run each note against a clean claim submission checklist before the claim leaves the practice. Auditors look specifically for region-technique pairings. A note that says “OMT performed to 3-4 regions” without naming them is one of the most frequent deficiencies in OMT post-payment reviews.

Billing CPT 98926 with an E/M visit on the same day

A DO or MD may bill an evaluation and management (E/M) visit on the same date as CPT code 98926. The E/M has to be a separately identifiable service.

The Modifier 25 requirement

When you bill an E/M and 98926 on the same date, append Modifier 25 to the E/M code, not the OMT code. Modifier 25 marks a significant, separately identifiable E/M service by the same physician on the same day.

Document the E/M separately from the OMT note, addressing a problem beyond what the OMT itself required. A common pairing is an established-patient visit billed as 99213 with Modifier 25.

The Modifier AT trap: Medicare requires Modifier AT (active/acute treatment) on chiropractic manipulation codes 98940-98942. It does not apply to physicians billing OMT. An AT on a 98926 claim signals a billing system configured for chiropractic rules. That can invite audits and damage your standing with your Medicare Administrative Contractor.

Confirm your billing software never auto-appends AT to OMT codes, and recheck the mapping whenever your code rules change.

Medicare and insurance coverage for CPT 98926

Medicare Part B covers OMT when it is medically necessary, per CMS coverage article 56954. It must be performed by a DO, or by an MD trained in OMT. Coverage applies in office and outpatient settings where the physician can provide E/M services.

Medicare coverage rules

• No statutory annual frequency limit applies to OMT under Medicare. CMS does not cap the number of OMT visits per year, but medical necessity must be established and re-documented at each encounter.
• Prior authorization is generally not required by Medicare for OMT. Individual MACs may still issue local coverage determinations (LCDs) with additional criteria, so check your MAC’s LCD for OMT.
• Place of service matters for reimbursement. Non-facility rates are higher than facility rates, and most OMT is billed at the non-facility (office) rate.
• Commercial payers vary significantly. Some require prior authorization for OMT beyond a set number of visits. Others restrict coverage to specific ICD-10 diagnoses. Verify individual plan policies before billing.

Submitting CPT 98926 claims electronically through a clearinghouse speeds up payer adjudication. Pabau, the practice management platform we build, connects to Claim.MD, its US clearinghouse partner. Claim.MD sends 837P claims to 4,000+ payers, including Medicare Administrative Contractors. It returns 835 remittances for automated payment posting.

How CPT 98926 reimbursement is calculated

Medicare pays CPT 98926 from three relative value units (RVUs): work, practice expense, and malpractice. CMS updates those RVUs and the conversion factor every year under the Physician Fee Schedule (PFS). A figure quoted from a past year is likely out of date.

Payment also varies by locality. Each Medicare payment locality adjusts the RVUs through its geographic practice cost index (GPCI), so the same claim pays differently across the country. Non-facility (office) rates run higher than facility rates.

Look up the current values for your locality in the CMS Physician Fee Schedule Look-Up Tool before quoting rates to patients or forecasting reimbursement. Our guide to OMT reimbursement rates explains how payment shifts across the whole 98925-98929 series.

Common reasons CPT 98926 claims are denied

OMT denials tend to repeat the same few patterns, and each one is preventable. A structured denial management workflow catches them before they compound.

• Body regions not individually documented. The note records a region count but does not name each region. Prevention: use a SOAP template that requires region-by-region documentation with a technique field for each.
• Wrong code selected. 98926 is billed when the note documents only two regions (98925) or five regions (98927). Prevention: code from the note, not from habit or a default code.
• Unsupported diagnosis code. A non-specific pain code with no matching M99 somatic dysfunction code fails payer medical necessity review. Prevention: always pair a non-specific pain code with the right M99 code.
• E/M bundled with OMT without Modifier 25. Payers auto-bundle same-day E/M and OMT. Prevention: put Modifier 25 on the E/M code and document the E/M as a separate note section.
• Modifier AT appended by the billing system. Chiropractic billing rules crossed into the OMT billing workflow. Prevention: audit your billing software configuration to confirm Modifier AT is not mapped to OMT codes.
• Provider not credentialed for OMT billing. A new physician joins the practice before payer enrollment is complete. Prevention: confirm credentialing is active for all payers before the first OMT claim.
• Frequency or utilization edits. Commercial payers may flag high-frequency OMT use for the same diagnosis. Prevention: document progress or a change in treatment rationale at each visit.

How Pabau supports osteopathic manipulative treatment billing

Many osteopathic practices chart OMT in one system and rebuild the claim in another. Region-by-region notes get re-keyed by hand, which is where a dropped region or a stray modifier slips in. Pabau’s claims management software carries the note straight into the claim instead.

• Structured clinical note templates capture each OMT body region with its own technique field, so the note supports the code level you bill.
• CPT code mapping for the full OMT family (98925-98929) cuts manual code selection errors at the point of billing.
• Claim scrubbing before submission catches modifier conflicts, missing diagnosis codes, and bundling issues before the payer sees them.
• Claim.MD clearinghouse integration handles electronic 837P submission, with eligibility checks and 835 remittance advice returned automatically.
• Denial tracking and reporting shows OMT denial rates by code and payer, so you can fix the workflow behind a pattern.

Modifier rules are enforced at the practice management layer, before a claim is transmitted. Your team spends less time on rework and appeals, and more OMT claims are paid on first submission.

Stop losing revenue to preventable OMT claim denials

Pabau’s claims management software maps CPT codes 98925-98929, scrubs claims before submission, and integrates with Claim.MD to send 837P files to 4,000+ payers. See how it works for osteopathic practices.

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Conclusion

Bill 98926 from the note, never from habit. If the note names three or four regions, each with its own technique and a supporting M99 finding, the claim holds up under review. If it records only a count, fix the note before the claim goes out.

The trade-off is a few more minutes of charting per visit. That costs far less than defending a batch of OMT claims in a post-payment review. Book a demo to see how Pabau carries region-by-region OMT notes straight into a scrubbed, ready-to-submit claim.

Continue your research

Need to understand how denials are categorized and appealed? Denial codes in medical billing covers CARC reason codes, appeal workflows, and how to read remittance advice.

Want a primer on what the ERA/835 file tells you after a claim is adjudicated? Electronic remittance advice explains how to interpret payment, adjustment, and denial information from payers.

Looking for guidance on insurance eligibility checks before the patient arrives? Insurance eligibility verification covers eligibility workflows that reduce claim rejections at the front desk.

Treating the sacrum as one of the regions? ICD-10 code M99.04 covers segmental and somatic dysfunction of the sacral region.

Frequently asked questions