Any Doctor of Osteopathic Medicine (DO) is familiar with the following question: “Hey Doc, what does that DO mean after your name?” While a detailed response regarding homeostasis and the musculoskeletal system could ensue, most of us tend to respond with some comment about osteopathic manipulative medicine (OMM). Unfortunately, most osteopathic emergency medicine (EM) residents have only vague memories of how to perform OMM and have since abandoned any hope of renascence.
Simply stated, OMM is a thought process regarding the usage of techniques to manipulate the musculoskeletal system, lymphatics, and nervous system to aid a patient's body in self-repair. Somatic dysfunctions are palpable tissue texture changes that can be treated to help the body restore homeostasis and reduce pain by a number of mechanisms. In osteopathic training, this thought process is obtained through the teaching of well-known techniques and palpatory exercises as part of a medical student curriculum.1
Unfortunately, the emergency department is often thought of as an “unfriendly place” for OMM. Physicians often lament that OMM is too time-consuming, that reimbursement is poor, and that skills are difficult to maintain with infrequent practice.1 In addition, there may be doubt that OMM is any more effective than oral or intravenous medication. However, studies have shown that OMM, when utilized alone or in conjunction with analgesic medication, is at least equally as efficacious in treating numerous musculoskeletal complaints such as acute low back pain, ankle pain, and neck pain, often lowering the amount of analgesic medication required for pain control.1,2,3
In this article we will explore the time constraints of OMM in the emergency department, the reimbursement structure for OMM and the skills needed for EM personnel to feel comfortable with these techniques.
Time is of the Essence
As a practicing EM physician who utilizes OMM on a daily basis, Benjamin Paschkes, DO, FACEP, would be the first to acknowledge that time management is paramount in the ED. Current practitioners tend to utilize simple but effective techniques in conjunction with the physical exam – much like the practice of OMM in outpatient primary care clinics.3 When done in this way, the practitioner may be able to provide immediate pain relief, improve the diagnostic accuracy of the physical examination, and add only minimal time to the full patient interview.1,3 A retrospective review of emergency room patients in osteopathic institutions over an 8-year period did not reveal any perceivable increase in patient length of stay when OMM was utilized.1
An additional avenue for hospital and ED osteopathic care is the utilization of osteopathic medicine consultation services. Such services do exist, such as the one at St. Barnabas Hospital in New York, which is run by Dr. Hugh Ettlinger and his colleagues. When it comes to time constraints, these services can be extremely useful in treating pain effectively and without the sedating effects of commonly used medications.
Additionally, patients requiring “more finesse” in terms of osteopathic manipulation (severe kyphoscoliosis, etc.) are better treated with a specialty service. “The small nuances...the finesse...the exact underlying somatic dysfunction”¦ this is the area of the osteopathic specialist,” states Dr. Paschkes. “But the use of simple techniques in the emergency department is more than possible for any EM physician.”
Show Me the Money!
Let's face it: Why would we waste precious emergency department time manipulating someone's neck or shoulder without any hope of reimbursement? Incentives come in many forms, but adequate reimbursement for skills is a tried-and-true method for getting results. With a small amount of documentation, only a fraction of time is needed to improve patient satisfaction, decrease patient, pain and increase the payroll.
Third-party payers such as Medicare, Medicaid, HMOs, and PPOs account for the primary income in health institutions. The American Medical Association's Current Procedural Terminology (CPT) codes allow for health care institutions to bill for anything and everything medical, including OMM. Currently, 5 billing codes are used for OMM documentation, depending on the area of the body treated. Many OMM techniques treat multiple body areas, allowing for multiple billing codes to be used for the same technique.4
On occasion, third-party payers may decline reimbursement for these services. However, with proper documentation, this is a rare occurrence.6 Additionally, any use of a modifier in the CPT codes can allow OMM to be billed as a separate service, avoiding service bundling. Many physicians do not do their own OMM billing, but have ensured that their credential list of billable techniques within their contracts contains osteopathic manipulation.3,5
Training and Physician Interest
Lack of interest in performing OMM is the biggest barrier to its implementation in emergency departments. Physicians practice what they are comfortable with, and those with little exposure may feel uncomfortable or unqualified to use OMM in their practice.
Additionally, many osteopathic emergency physicians feel it is merely a “primary care thing,” leading to biases against its timely usage in an emergency department setting. Fortunately, there is strong allopathic support for legislation favoring the American Osteopathic Association (AOA) to allow paths for OMM training for residents and attendings. With the ACGME merger, it seems only a matter of time before allopathically trained residents who are interested in OMM can receive adequate training and billing rights.4
The basics of osteopathic training are well within reach for allopathic physicians who wish to utilize OMM in their practice. The mere drive to learn and utilize osteopathic manipulation is the most essential first step. Currently, the American Academy of Osteopathy (AAO) welcomes MDs to many of their conventions and classes. With the current merger, it seems likely that such workshops will become even more common.
Finally, issues regarding liability further dissuade those unfamiliar with OMM from learning or practicing their skills. However, literature shows that with proper understanding of indications and contraindications, there are few medical modalities that are safer.3 Moreover, after manipulation in the ED, follow up with a fellowship-trained, outpatient osteopathic physician can then be arranged for further management, particularly in refractory pain cases.
Conclusion
In conclusion, OMM is a fast, safe, billable, and widely accessible skill set that is underutilized in the emergency department setting. This approach also tends to provide the practitioner with a more thorough and accurate physical examination, as well as a more personal relationship with his or her patients.1 Both osteopathic and allopathic physicians who are eager to learn about or improve their OMM skills should assist with future research efforts and improvements in existing protocols for pain management within the ED.
Special thanks to Benjamin N. Paschkes, DO, FACEP, FAAEM, and Regina Hammock, DO, for their assistance with this article.
References
- Ault B, Levy D. Osteopathic manipulative treatment use in the emergency department: a retrospective medical record review. J Am Osteopath Assoc. 2015;115(3):132-137.
- McReynolds TM, Sheridan BJ. Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: a randomized clinical trial. J Am Osteopath Assoc. 2005;105(2):57-68.
- Roberge RJ, Roberge MR. Overcoming barriers to the use of osteopathic manipulation techniques in the emergency department. West J Emerg Med. 2009;10(3):184-189.
- (NIDA), N.I.o.D.A. Overdose Death Rates. 2015 December 2015. Available from: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
- Snyder KT. Billing and Coding for Osteopathic Manipulative Treatment. J Am Osteopath Assoc. 2009;109(8):409-413.