In general DO's and MD's can charge more for manual therapy because of the higher reimbursement for physician evaluation and management (E&M) compared to chiropractors. Also, OMT is considered a procedure so you can bill for it using a special -25 modifer. If you do more than one procedure per visit---i.e. trigger point and OMT---you can charge separately for each. Here's good article that summarizes the coding/billing issues with OMT
ACOFP OMT Billing Article
Now, reimbursement is a completely separate issue. Reimbursement from medicare (which is essentially the benchmark for other private insurances) is based upon a complicated formula that utilizes RVU's (relative value units) for every kind of office/hospital procedure or visit. The 2004 formula's conversion factor is $37.3374, representing a 1.5 percent increase from 2003. You multiply $37.34 x the RVU to get the total reimbursement:
So,
has a HYPOTHETICAL example let's say that a new patient is referred to you for neck and arm pain. You do a thorough history and physical exam and review outside records and think that an EMG is needed (which you perform). Here's what medicare will reimburse:
99203 Office visit new, level 3: 2.57 X 37.24 = $95.70
95861 EMG 2 limbs global: 3.08 X $37.34 = $115.00
Total: $210.00
The EMG is normal and you believe that the pain is musculoskeletal and/or myofascial in origin. You refer the patient for PT and have them follow-up with you in two weeks. You re-evaluate the patient in two weeks and it seem that there has been only minimal improvement in their symptoms. You re-examine the patient and believe that there is an element of somatic dysfunction involved in the cervical spine. You offer to try a trigger point injection and some OMT to see if this helps with therapy. You have them return to therapy and follow-up in a couple of weeks. Here's what medicare will reimburse:
99211 Office visit established, level 1: .57 X $37.24 = $21.23
20553 Injection(s); single or multiple trigger point(s): 1.66 X $37.24 = $38.90
98925 OMT 1-2 body regions: 1.35 X $37.24: = $50.27
Total: $110.40
The patient returns and reports modest improvement following the injection and OMT. Things are progressing well in therapy. You review the therapist's notes and re-examine the patient. The patient's pain has now essentially become more focally located over the right C5-C6. You happen to be well trained in interventional spine procedures
🙂 and after reviewing an MRI and plain films offer to try a cervical facet (no-flouro because you indeed are VERY skilled, otherwise you could charge for the flouro). Here's the break down:
99211 Office visit established, level 1: .57 X $37.24 = $21.23
64470 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level: 6.85 X $37.24 = $255.10
Total: $276.33
I've undercoded some of the office visit E&M stuff just to keep it simple: You get more money for reviewing tests and imaging and "coordinating care" etc, but it get's complicated fast. But, I think that moral of the story is clear: You don't make money on office visits (especially with established patients with fairly straightforward medical issues---i.e. primary care), procedures pay and you need to do procedures to make money, currently OMT and injections are billed as separate procedures, but a lot of insurance companies want to "bundle" codes so that you can't bill separately (that's why you need to be politically involved in your professional organizations who lobby for you), you want to constantly be attracting NEW patients to your practice---i.e. you want to develop a consultative type practice---and have them "follow-up" with their primary care physician for other ongoing concerns.
The above scenarios don't take into consideration other sources of revenue like where the physiatrist owns or is part owner in a PT gym, MRI facility or outpatient surgery center (i.e. flouro arrangements). These arrangements get tricky but typically help improve overall cash-flow.
Hope that helps.
