Incorporating OMM to Enhance Your Clinical Practice

OMM clinical integration Patient centered approach

Sheldon C. Yao, D.O. Acting Department Chair

March 1, 2013

How to integrate OMT in your practice

• Discuss barriers from utilizing OMT • Explaining osteopathic medicine through 4

tenets • Developing an approach through the 5

models of osteopathic care • Justification through evidence and literature • Review documentation and coding

Barriers?

• Approaching patients • Time • Confidence • Office equipment (tables) • Documentation? • Coding/Billing?

Four Tenets of Osteopathic Medicine

Figure 1. A graphic depiction of the four general principles of osteopathic medicine - J Am Osteopath Assoc. 2005;105:S6-S11.

Somatic Dysfunctions

• Definition - 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.

• Diagnosis T - tissue texture

abnormalities A - asymmetry R - range of motion

abnormalities T - tenderness

Osteopathic Manipulative Medicine – Goals of Treatment

1. Relief of pain and reduction of other symptoms 2. Improvement of function 3. Increased functional movement 4. Improved blood supply and nutrition to the

affected areas. 5. Sufficient return flow of fluids via the lymphatic

and venous systems 6. Removal of impediments to normal nerve

transmission

Approach to treatment

• An osteopathic approach takes into consideration how the physician can manually diagnose and treat somatic dysfunctions that is contributing to the patient’s pain and preventing optimal health and healing.

• Utilize 5 models of osteopathic care as an approach you patient.

Structural model • Goal is to optimize biomechanical restoration

and mobilization of joints. • Addresses bones, myofascial, soft tissue to

maximize movement. • Common etiologies for structural DS =

articular restrictions/asymmetry & myofascial elastic changes in tissue texture or function

• Treatments used in the structural model include: HVLA, muscle energy, MFR - soft tissue, counterstrain, FPR, BLT, Still’s

Respiratory Circulatory model • Goal is to improve respiratory and circulatory/

lymphatic flow. 1. improve motion of the thoracic cage 2. addressing any diaphragm restrictions 3. promote fluid movement through pumps • Increased respiration and circulation --> increase

oxygenation --> healthier tissues • Treatments used in the Resp/Circ model include:

Lymphatic pumps, diaphragm doming, TOR, OCF, MFR, BLT

OMT to promote lymph flow • Always first treat

regions of possible obstruction – treat from proximal to distal.

• Improve thoracic compliance and diaphragm movement

• Augment lymph flow with pumping techniques first ensuring that there are no contraindications

Neurologic model • Goal: attain autonomic balance and address

neural reflex activity, remove facilitated segments, decrease afferent nerve signals, relieve pain.

• Address musculoskeletal restrictions that may be compression on nerves. Help decrease spasm and pain to break V-S faciliation.

• Treatments used in the Neurologic Model include: Rib Raising, Suboccipital release, Soft tissue inhibition, counterstrain, muscle energy, Chapman reflex points

OMT to improve thoracic compliance and balance sympathetic tone

• Myofascial release • Muscle energy to

clavicles, rib, and spine • Inhibition to accessory

muscles of respiration • Articulatory techniques

to the thoracic spine and ribs

• Rib raising (seated or supine)

OMT to address parasympathetic innervation

• Suboccipital release • OA decompression • Myofascial to upper

cervical region • BLT to upper cervical

spine

5 Models of Osteopathic Care

• Behavioral Model • Goal: improve biological, psychological, social

components of health

• Metabolic Model • Goal: enhance self-regulatory and self-healing

mechanisms

Application of OMT

• Geriatrics – arthritis, restriction in range of motion, kyphoscoliosis

• Pediatrics – plagiocephaly, torticollis, chronic otitis media, asthma, JRA, scoliosis, cerebral palsy, Down Syndrome, ADHD, autism

• Obstetrics – low back pain, CTS, edema, pelvic pain and congestion, post-partum

• Athletes – sports medicine, musculoskeletal injuries, injury prevention, strength and conditioning

Application of OMT • Cardiology CAD, CHF, HTN, Arrhythmias, Angina • ENT URI, Sinusitis, OM, Pharyngitis, TMJ • Pulmonary Bronchitis, Pneumonia, COPD,

Asthma, Cystic Fibrosis • GI GERD, Crohn’s, UC, IBS,

Constipation • GU Dysmenorrhea, Pelvic pain, Urinary

incontinence, Nephrolithiasis

• Surgery Post-op complications, Ileus,

Atelectasis • Emergency Medicine Trauma, Musculoskeletal pain • Neurology Headaches, Spinal disorders,

entrapment neuropathies • Orthopedics Joint laxity or instabilities,

Osteoarthritis, Back Pain • Rheumatology RA, Spondyloarthropathies,

Fibromyalgia • Oncology Lymphedema

Evidence based medicine

Osteopathic Manipulative Medicine as an option for complete care

• Educate your patient – Give patients an option of a trial of OMT first (if appropriate) – Explain to the patient the concept of OMT through tenets or 5 models. – Obtain informed consent.

• Treatment – Use techniques that you know and feel comfortable performing. – Show restraint (don’t look to “fix” everything today). – Explain potential side effects. – Discuss what you are doing and how it is helping their body.

• Follow up care and expectations – Once a week for 2-3 weeks then try to extend time between visit. – If no improvement consider alternative or reevaluation. – Recommend exercise prescription and lifestyle and nutritional changes – Give realistic expectation of improvement.

Performing a Focused Exam

• Incorporate you structural examination into your physical examination

• Select targeted and key areas to scan for dysfunction • Give yourself 1 minute to find the areas most

restricted and most painful • With practice this will become easier and smoother • Demo

Documentation

• OMT is a procedure. Must have a procedure note with findings clearly listed and treatment modalities applied.

• New – push for documentation of severity of the dysfunction and response to treatment

• Documentation is the same whether office or hospital

• Keep documentation pertinent

Sample OSE documentation • OSE (Osteopathic Structural Examination)

• Head – OAFSRRL (3) – tx with MET (1) • Cervical – C2FSRR (2) – tx with HVLA – 0, right

SCM spasm (1) tx with MFR (0) • Rib – right 1st rib inhalation dysfunction – tx

with Still’s technique (0) • Thoracic – T2-5NSRRL (1) – tx with FPR (0)

• Key mild (1), moderate (2), severe (3)

ICD-9 Codes Somatic Dysfunction Codes are used as your diagnosis code • 739.0 Head/Cranial Somatic Dysfunction (SD) • 739.1 Cervical SD • 739.2 Thoracic SD • 739.3 Lumbar SD • 739.4 Sacral SD • 739.5 Innominate (Pelvis) SD • 739.6 Lower Extremity SD • 739.7 Upper Extremity SD • 739.8 Rib SD • 739.9 Abdominal/Visceral SD

OMT CPT Codes (Procedure)

• 1-2 areas treated 98925 • 3-4 areas 98926 • 5-6 areas 98927 • 7-8 areas 98928 • 9-10 areas 98929

• 10 areas are Cranial, Cervical, Thoracic, Lumbar,

Sacral, Innominate, Upper Extremity, Lower Extremity, Rib cage, Visceral.

Modifiers • -25 modifier: Significant, separately identifiable

evaluation and management (E/M) service by the same physician* on the day of a procedure

• Important to document to support use of this modifier

• E/M (HPI, PE, complexity of care must be present)

• OMT is a separate and distinct procedure that was indicated after proper E/M

Putting it together: Coding • Office visit. Patient seen and evaluated, OMT

performed for headache • E/M: 99213 (est patient, mod complex) • Diagnosis: HA (784.0) [SD should never be

only dx code – does not justify office visit. SD (739.0,1,2,8)

• Procedures: OMT 4 region 98926 • Add -25 modifier 99213 -25 mod

Additional resources

• American Academy of Osteopathy • http://netforum.avectra.com/eweb/StartPage.

aspx?Site=AAO • American Osteopathic Association • https://www.osteopathic.org/Pages/default.a

spx

Summary • Identify barriers that is preventing

you from utilizing OMT in your practice

• Develop routine to incorporate OMT • Provide patient education and

opportunity • Develop your own approach that fits

within your practice • Practice and know what resources

you can utilize to support OMT in your practice

Questions?

Benjamin 4 yo Lydia 22 months