Why OMM ?

W I L L I A M C . S I M O N D O N E W M E D I C A L H E A L T H C A R E

What is OMM?

Osteopathic manipulation is a treatment that attempts to improve joint range of motion and balance tissue and muscular mechanics. Improve function and decrease pain and suffering

What is OMM used for?

         Headaches Back pain Shoulder dysfunction and pain Carpal Tunnel Syndrome Strains and sprains SOB Chest pain with rib dysfunction Colic Just to name a very few

OMM is used to treat:

        musculoskeletal pain conditions, such as back pain, shoulder pain, arthritis, and tension headaches .

Some advocates of OMT believe that it has numerous other benefits, including:

Upper respiratory infections Fibromyalgia Asthma Carpal tunnel syndrome Pneumonia Bronchitis Overall health and well-being

Osteopathic history

Evolution of Osteopathic Medicine

     

Evolution of osteopathic medicine's mission and identity took Years to evolve:

1892 to 1950 Manual medicine 1951 to 1970 Family practice / manual therapy 1971 to present Full service care / multispeciality orientation

1916-1966, Federal recognition

Recognition by the US federal government was a key goal of the osteopathic medical profession in its effort to establish equivalency with its MD counterparts. Between 1916 and 1966, the profession engaged in a "long and tortuous struggle" for the right to serve as physicians and surgeons in the U.S. Military Corps

Years States Passed unlimited practice rights for DOs, equal to those of MDs

● ● ● Early, 1901-1930 Middle, 1931-1966 Late, 1967-1989

Osteopathic Schools in red Percentage of all physicians Percentage Colors from light to dark

●

Geographic distribution of osteopathic physicians as a percentage of all physicians, by state. <3% 3-5% 5-10% 10-15% 15-25

Osteopathic Medical Schools

 Midwest & Plains AT Still Kirksville , Des Moines COM , Kansas City COM , Michigan State , Midwestern Chicago , Ohio COM , Oklahoma State  Northeast Lake Erie COM , New England COM , New York COM , Philadelphia COM , Touro Harlem , UMDNJ-SOM  Southeast Lake Erie COM, Bradenton , Lincoln Memorial , North Texas COM , Nova Southeastern , Philadelphia COM Georgia , Pikeville KYCOM , Virginia COM , West Virginia SOM , William Carey COM  West AT Still Arizona , Midwestern Arizona , Pacific Northwest , Rocky Vista , Touro California , Touro Nevada Western  Currently, there are now 26 accredited osteopathic medical schools offering education in 34 locations in the United States and 126 accredited US (MD) medical schools.

Osteopathic Schools

 In 1960, there were 13,708 physicians who were graduates of the 5 osteopathic medical schools.

 In 2002, there were 49,210 physicians from 19 osteopathic schools.

 Between 1980 and 2005, the number of osteopathic graduates per year increased over 250 percent from about 1,000 to 2,800. This number is expected to approach 5,000 by 2015.

Osteopathic Training

The osteopathic medical school curriculum is clearly distinguished from allopathic medical education by its focus on osteopathic manipulative medicine (OMM), a hands-on therapy that is used to diagnose and treat illness and injury. OMM education usually occurs through year-long first and second year theoretical and skills courses, and through subsequent clinical experiences. OMM education is in addition to, and integrated with, medical training on current and emerging theory and methods of medical diagnosis and treatment.

Osteopathic Training and Trends

 Osteopathic medicine is considered by some in the United States to be both a profession and a social movement , especially for its historically greater emphasis on primary care and holistic health . However, any distinction between the MD and the DO professions has eroded steadily; diminishing numbers of DO graduates enter primary care fields, fewer use OMM, holistic patient care models are increasingly taught at MD schools, and increasing numbers of DO graduates choose to train in non osteopathic residency programs.

Trends in Osteopathic Primary Care

Trends in primary care as a career choice of osteopathic medical students 4th year students dark blue 1st year students light blue

Physicians Entering the Work Force

Graduate Medical Education

Total Number of DO’s in Residency Training Programs, by Year.

Blue is DO residents in ACGME (MD) programs.

Red is DO residents in AOA (DO) programs.

Manipulation in Practice

 A 2001 survey of osteopathic physicians found that more than 50% of the respondents used OMT on less than 5% of their patients. The survey follows many indicators that osteopathic physicians have become more like MD physicians in every respect —few perform OMT, and most prescribe drugs or suggest surgery as a first line of treatment.

Manipulation in Practice

 Recent studies show an increasingly positive attitude of patients and physicians (MD and DO) towards the use of manual therapy as a valid, safe and effective treatment modality. One survey, published in the Journal of Continuing Medical Education , found that a majority of physicians (81%) and patients (76%) felt that manual manipulation (MM) was safe, and over half (56% of physicians and 59% of patients) felt that manipulation should be available in the primary care setting. Although less than half (40%) of the physicians reported any educational exposure to MM and less than one-quarter (20%) have administered MM in their practice, most (71%) respondents endorsed desiring more instruction in MM.

Manipulation in Practice

 Another small study examined the interest and ability of MD residents in learning osteopathic principles and skills, including OMM. It showed that after a 1-month elective rotation, the MD residents responded favorably to the experience

OMM vs Standard Medical Treatment Study

  

A Comparison of Osteopathic Spinal Manipulation with Standard Care for Patients with Low Back Pain

Gunnar B.J. Andersson, M.D., Ph.D., Tracy Lucente, M.P.H., Andrew M. Davis, M.D., M.P.H., Robert E. Kappler, D.O., James A. Lipton, D.O., and Sue Leurgans, Ph.D.

N Engl J Med 1999; 341:1426-1431 November 4, 1999

OMT Study

 They performed a randomized, controlled trial that involved patients who had had back pain for at least three weeks but less than six months. They screened 1193 patients; 178 were found to be eligible and were randomly assigned to treatment groups; 23 of these patients subsequently dropped out of the study. The patients were treated either with one or more standard medical therapies (72 patients) or with osteopathic manual therapy (83 patients). They used a variety of outcome measures, including scores on the Roland– Morris and Oswestry questionnaires, a visual-analogue pain scale, and measurements of range of motion and straight-leg raising, to assess the results of treatment over a 12-week period.

OMT Study Results

 Patients in both groups improved during the 12 weeks. There was no statistically significant difference between the two groups in any of the primary outcome measures. The osteopathic-

treatment group required significantly less medication (analgesics, antiinflammatory

agents, and muscle relaxants) (P< 0.001) and used less physical therapy (0.2 percent vs. 2.6 percent, P<0.05). More than 90 percent of the patients in both groups were satisfied with their care.

Cervical OMM

Cervical Manipulation and Stroke Risk

 Stroke with cervical manipulation is estimated to be 1 in 400,000 to 1 in 5.8 million  NCMIC Chiropractic solutions concluded: “the incident of stroke in the population as a whole is no different, with about 2 per 100,000 anually, than those who received manipulations of the neck.”

     Neck strains Headaches Sinus Problems Stiff neck Arm numbness

Cervical OMM

Cervical Manipulation has Lots of Techniques

Thoracic Manipulation

Thoracic Manipulation

    SOB with rib release Chest pains (not cardiac related unless stable) Upper back pains Shoulder pains  Lots of people have pains in this area from purses, backpacks and leaning over to do daily work

Lumbar Manipulation

Lumbar Manipulation

      Majority of back issues Sciatica Radiculitis Abdominal pain Usually spasms are cause for most pain Obesity is a contributal cause  Related to daily activities such as lifting, twisting, stooping and bending

McRib and McBack Pain

Obesity, Back Pain and Workers’ Comp

 Obesity was particularly linked to workers’ comp claims for falls, slips, lifting, exertion, back pain, and injuries to the hand, wrist, knee, hip and ankle!

 Physically demanding jobs carry the greatest risks!

Obesity, Back Pain and Worker’s Compensation

 Medical costs per 100 workers     

Normal BMI: $7,500 (18.5-24.9) Overweight: $13,300 (25.0-29.9) Mildly Obese: $ 19,000 (30.0+) Moderately Obese: $23,000 (>40) Severely Obese: $51,000 (>50)

 Researchers found that the number of workdays lost was almost 13 times higher, medical costs 7 times higher and indemnity claims costs were 11 times higher among the heaviest employees compared to those of normal weight

Medical Costs of Back Pain Related to Obesity

Back Pain

Medical costs per 100 workers $51 000 $23 000 $19 000 $13 300 $7 500 Normal BMI Overweight Mildly Obese Moderately Obese Severely Obese

Back Pain is a Leading Cause of Work-Loss Days

    83 million days of work are lost each year due to back pain Back pain is a leading cause of work-loss days as well as work limitations.

Adults with back pain spend almost 200 million days a year in bed!

A larger proportion of back pain patients report feeling sad, worthless or hopeless.

Days Lost from Work for Various Injuries

Neck; 2% Head; 7% Lower 21% Body /Multiple parts, 10% Extremities; Upper extremities; 23% Trunk; 12% Back ; 25%

Proportion of Adults with and without Back Pain Who are Working

100 90 80 30 20 10 0 70 60 50 40 18 to 44 45 to 64 65+ With back pain Without back pain

Median Annual Earnings of Adults With Work Limitations Due to Back Pain, by Age

$23,160

Median Income

With Back Pain Without Back Pain $29 700 $21 909 $15,600 18 to 44 45 to 64

Adults With and Without Back Pain Using Various Health Care Services

Without Back Pain With Back Pain Physical or Occupational Therapist 2 8 Chiropractor 2 20 Physician visits Prescription drugs 66 83 65 83

Health Care Expenditures for Adults With and Without Back Pain

Prescription Drugs

Health Care Visits

Without Back Pain With Back Pain 244 Physician Visits Non-Physician Visits ER Visits 103 223 203 275 304 367 370

Effects of Back Pain on Retirement

With Back Pain Satisfaction with retirement with back pain

Not at all Moderate Very 12% 50% 38%

Without back pain Satifaction with retirement without back pain

Not at all Moderate 6% Very 29% 65%

Cost of Back Pain

 In 2005 Americans spent $85.9 billion looking for relief from back and neck pain, through surgery, doctors’s visits, xrays, MRI’s and medications.

 This is up from $52.1 billion in 1997.  According to the JAMA, that money has not helped reduce the number of sufferers; in 2005, 15% of U.S. adults reported back problems, up from 12% in 1997

Cost of Back Pain

 Researchers at the University of Washington and Oregon Health Science University compared national data from 3,179 adult patients who reported spine problems in 1997 to 3,187 who reported them in 2005 and found that inflation adjusted costs increased from $4,695 per person to $6,096.

Cost of Back Pain

Number with back pain $6 096 Cost of treatment $4 695 3 179 3 187 1997 2005

Was That in the P.I.?

Chiropractic Cost-Effectiveness

 Blue Cross Blue Shield of Tennessee conducted a study in 2010 that took place over a 2 year period.  85,000 BCBS subscribers in the insured study population had open access to MDs and DCs through self-referral, and there were no limits applied to the number of MD/DC visits allowed and no difference in co-pays. Thius this study reveals what happens when Chiropractic and Medical services compete on a level playing field.

Chiropractic Cost-Effectiveness

 The researchers compared the costs of low back pain care initiated by a DC with care initiated through a MD or DO. They found that costs for the DC group were 40% lower.

 Even after factoring in the severity of the conditions with which patients presented, costs when a DC initiated care were 20% lower than if a MD/DO initiated care.

Who does Manipulation?

 Osteopaths are trained to do manipulation  Only a small percentage do OMM  Chiropractors are trained to do manipulation  Most DCs do some form of manipulation  Physical Therapists are trained to do manipulation  Are now PhDs wanting more indivdual practice rights  Massage Therapists-some do types of manipulation  Others such as DOM, Naturopaths and Homeopaths have manipulation traiing

How long does it take to do OMM?

     It takes anywhere from 1 minute to 30-40 mins depending on the treatment, method and extent.

HVLA is usually fairly quick Strain-counterstrain usually takes 1 to 3 mins per area Cranial usually takes 5-10 mins depending on findings and areas Visceral takes about 5 min

How We Feel with Insurance Companies

TART Documentation

 T: Tissue texture change; stability, laxity,effusions, tone  A: Asymmetry; misalignment,crepitation,defects, masses  R: ROM; contracture, ease of movement  T: Tenderness; pain, discomfort

OMT Documentation

1. Perform and document a thorough history and examination.

2.Determine, perform and document theraputic and diagnostic intervention.

3. Put Somatic Dysfunction and the OMT Code first on encounter forms "Somatic Dysfunction as noted above" in your dictation.

4. List secondary diagnosis on encounter forms and in dictation.

5. Use the -25 Modifier on the E&M Code for your secondary diagnosis.

OMT Documentation

 When documenting OMT, use the documentation guidelines three key components of history, examination and medical decision making (MDM).  The history should have a chief complaint, history of present illness, review of systems and a past medical, family and/or social history.  Your physical examination would include your musculoskeletal structural examination and any germane body area or organ systems. The history and physical examination should contain information germane to the complaint or be part of a workup to rule out specific pathology. One should not add components to the history or physical simply to enhance the documentation.

OMT Documentation



25 Modifier

 Modifiers are designed to better describe a code or how that code is being used in conjunction with another code or modifier. Typically it is used for two unrelated problems such as a treating a UTI at the time of an excisional biopsy.

OMT Documentation

 With OMT, the diagnosis somatic dysfunction is listed first with the correlating ICD code(s) and CPT code without a modifier. The second, third and/or fourth diagnoses are listed and these justify or create medical necessity for the E&M service billed (your consult, in or outpatient codes). The E&M code gets a modifier here just like the UTI example, but the

E&M code need not be for a separate problem and can in fact be what prompted the OMT.

My Documentation

Cervical Exam Manipulation done to this area, Lesions found were corrected. Cervical Tissue Tissue tenderness tightness, Boggy on the right. ROM slightly decreased.

Cranial Exam Cranial dysfunctions were evaluated and corrected as needed. Decreased motion noted. Feels Decreased motion Tight on the right.

Ilium Exam Iliac dysfunctions were evaluated and corrected as needed.. Findings Right Ilium Rotated Posterior.

Lumbar Exam lumbar dysfunctions were evaluated and corrected as needed. Findings Paravertebral tightness was noted. Feels tenderness to palpation with Decrease Motion. Lordos is Normal.

Sacrum Exam Sacral dysfunctions were evaluated and corrected as needed. Sacral dysfunction Abnormal findings were noted Paravertebral Tightness Bilaterally. ROM Stuck in Extention. Feels Tender with Decreased motion.

Thoracic Exam Thoracic Dysfunctions were evaluated and corrected as needed.. thoracic Thoracic tightness noted really tight between shoulder blades. Muscle Involvement Rhomboids Thoracic paravertebrals tightness is noted.

Extremities Right wrist Manipulation done. Shoulder Bilaterally, Tenderness to palpation. Hip decreased ROM, Pain with palpation. Articulatory technique was done

What are the Benefits of Manipulation?

 It helps patients by:      Reducing pain and suffering Returning them to normal state quicker Retuning them to work faster Increases function Reducing medication needs  It helps you by:     Getting results, which makes you look better Increasing your referral base because you get results Increases your reimbursement and bottom line Helping you feel more comfortable with each OMT done

  98925 (1-2) BC $51.83

  98926 (3-4) BC $71.44

  98927 (5-6) BC $93.86

  98928 (7-8) BC $109.28

  98929 (9-10) BC $124.84

Payment for OMT

  98925 Medicare $29.13

  98926 Medicare $39.12

  98927 Medicare $50.99

  98928 Medicare $59.55

  98929 Medicare $68.69

Top 10 Reasons to do OMM

          1. Patients like it and you can make more money!

2. Results can be amazing!

3. You can get a workout!

4. You get paid to beat up on people!

5. You are called a masochist!

6. You can hurt patients and they ask to come back!

7. You get to hear your patients say, “You enjoy hurting me, don’t you!” (because they see the smile on your face) 8. Not everyone can do this!

9. You can hurt people and get away with it!

10. People seek you out!

The End is Near

You are an OSTEOPATH!

 Think like an Osteopath!

 Rule out the serious causes and then fix the problem  To be a good Osteopath you need to “think” with your hands  Trust what you feel  There is a treatment for most everyone, soft tissue techniques work well, you don’t have to hear bones crunch to get results!

Questions?

References

^

a b c d e f

Zuger A.

Scorned No More, Osteopathy Is on the Rise.

New York Times. 17 Feb 1998.

^

a b

Gevitz, N. (1 April 1994). "'Parallel and distinctive': the philosophic pathway for reform in osteopathic medical education" (Free full text). The Journal of the American Osteopathic Association 94 (4): 328–332. ISSN 0098-6151 . PMID 8027001 . http://www.jaoa.org/cgi/pmidlookup?view=long&pmid=8027001 .

^

Lloyd, Janice.

Doctor shortage looms as primary care loses its pull.

edit USA Today. 18 Aug 2009. Accessed 08 Sept 2009.

^

a b c d

doi : Shannon, S.; Teitelbaum, H. (Jun 2009). "The status and future of osteopathic medical education in the United States". Academic medicine : journal of the Association of American Medical Colleges 84 (6): 707–711. 10.1097/ACM.0b013e3181a43be8

. ISSN 1040-2446 . PMID 19474542 .

edit ^

a b c

Gevitz, N. (Jun 2009). "The transformation of osteopathic medical education". Academic medicine : journal of the Association of American Medical Colleges 84 (6): 701–706. doi : 10.1097/ACM.0b013e3181a4049e

. ISSN 1040-2446 . PMID 19474540 .

edit ^

a b

Cohen, J. (Jun 2009). "The separate osteopathic medical education pathway: isn't it time we got our acts together? Counterpoint". Academic medicine : journal of the Association of American Medical Colleges 84 (6): 696. doi : 10.1097/ACM.0b013e3181a3ddaa

. ISSN 1040-2446 . PMID 19474536 .

edit

References

^ "AAMC Medical Schools" . Association of American Medical Colleges. http://www.aamc.org/medicalschools.htm

. Retrieved 2006-12-13.

^

Salsberg, E.; Grover (Sep 2006). "Physician workforce shortages: implications and issues for academic health centers and policymakers". Academic medicine : journal of the Association of American Medical Colleges 81 (9): 782–787. doi : 10.1097/00001888-200609000-00003 . ISSN 1040-2446 . PMID 16936479 .

edit ^ Geographic Map of Colleges of Osteopathic Medicine.

AACOM.

^ About the AOA.

American Osteopathic Association. Accessed March 2008.

^ How many DOs are there in the United States?

Journal of Manipulative Physiol Ther 2010(Nov); 33(9): 640-643