Cliff Notes: Same‑Day E/M + OMT (Modifier 25)
The Golden Rule
The work, not the diagnosis, determines whether you can bill an E/M with OMT on the same day.
OMT’s Inherent Work – DO NOT bill E/M for this
- Technique selection & order
- Palpatory assessment to find somatic dysfunction
- Explaining procedure & obtaining consent
- Positioning patient
- Performing manipulation
- Reassessment during/after treatment
- Post‑care instructions & documentation
➡️ These activities are NOT an E/M service.
What Qualifies as a Separate E/M Service (bill with modifier 25)
- Taking a history (HPI, review of systems, etc.)
- Performing an examination beyond palpatory assessment (e.g., neurologic, musculoskeletal, cardiovascular)
- Medical decision‑making (MDM) – diagnosing, ordering tests, adjusting medications, referrals, changing treatment plan
➡️ The decision to perform OMT is part of MDM. It does NOT disqualify modifier 25.
The Simple 3‑Question Test (Same Day)
1.Did you do significant E/M work (history, exam, MDM) beyond OMT’s inherent work?
- No → Bill OMT only.
- Yes → Go to next.
2. If OMT were not performed, would the E/M note stand alone?
- No → Bill OMT only.
- Yes → Go to next.
3. Does documentation clearly separate the E/M work from OMT work?
- No → Bill OMT only.
- Yes → Bill E/M + modifier 25 and OMT.
When Modifier 25 Is NOT Needed
- E/M and OMT on different days → Report E/M on its date (no modifier), OMT on its date (no modifier).
Common Denial Traps & Counterarguments
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Insurer’s Typical Denial Reasons
(Cite these rules) Bases On CPT and CMS Rules
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Valid Denial?
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“E/M led to decision to perform OMT, so modifier 25 cannot be used.”
The decision to perform rule applies only to major surgeries (modifier 57). OMT is a minor procedure (000‑day). Modifier 25 is correct.
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❌ No |
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“E/M is bundled because same diagnosis.”
CPT OMT guidelines: work, not diagnosis, determines separate reporting. Same diagnosis is allowed.
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❌ No |
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“E/M evaluation is part of the pre-service work of OMT.”
CMS reduced OMT pre‑service time by 1 minute (2011 rule). OMT inherent work includes no history, no E/M‑style exam, no MDM.
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❌ No |
Documentation Shortcut
Document two distinct parts (can be in one note):
- E/M part: History, exam, MDM (e.g., “Patient with acute worsening of low back pain, new radicular symptoms. Neurologic exam performed. Plan: MRI, medication change.”)
- OMT part: Somatic dysfunction, regions treated, techniques, response.
Example Scenarios – At a Glance
| Scenario |
Modifier 25? |
| New patient comprehensive workup + OMT |
✅ Yes |
| Established patient requiring reassessment unresolved issue(s) |
✅ Yes |
| Patient with new unrelated problem + OMT |
✅ Yes |
| OMT only visit (even if new patient, but no significant E/M) |
❌ No |
| E/M on Monday, OMT on Wednesday |
No modifier (different days) |
Bottom Line
If you do real E/M work (history, exam, MDM) that would be necessary even without OMT, you can and should bill it with modifier 25. Do not let insurers invent rules that contradict CMS, NCCI, and CPT.
For More Help
The American Academy of Osteopathy (AAO) offers additional coding, billing, and auditing resources in the Practice Management section of our website.
If you would like to schedule a one‑on‑one meeting or phone call to discuss specific questions or challenging cases, please contact:
Kavin Williams
Email: [email protected]
Phone: 773-320-0926
We are here to help you get paid accurately for the essential work you do.
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