Osteopathic Manipulations (OMT) | UHC Coverage Update

TL;DR: UnitedHealthcare modified its osteopathic manipulative treatment coverage policy (policy code: osteopathic-manipulations-omt) effective September 26, 2025. Here's what billing teams need to do.

UnitedHealthcare updated its Medicare Advantage medical policy for osteopathic manipulative treatment, covering CPT codes 98925 through 98929. The UHC OMT coverage policy now ties reimbursement directly to documented somatic dysfunction — specifically the TART criteria — and aligns local coverage determination (LCD) compliance requirements for applicable states. If your practice bills OMT under Medicare Advantage, this policy change affects your documentation standards, your E&M billing decisions, and your exposure to claim denial.

Quick-Reference Table

UnitedHealthcare OMT Coverage Criteria and Medical Necessity Requirements 2025

The UHC OMT coverage policy covers osteopathic manipulative treatment when it's medically necessary, performed by a qualified physician, and the patient's history and physical exam show somatic dysfunction in one or more body regions. That's the baseline. But the details matter more than the headline.

Medical necessity here isn't abstract. UnitedHealthcare requires conventional documentation of somatic dysfunction in the patient's medical record. Specifically, the record must reflect findings consistent with the TART acronym: tenderness, asymmetry, restriction of motion, and tissue abnormality. If your notes don't document at least one of these findings, you don't have a covered claim — you have a denial waiting to happen.

The policy covers six OMT technique categories: muscle energy, high velocity-low amplitude (HVLA), counterstrain, myofascial release, visceral, and craniosacral. The technique itself isn't the coverage determinant. Documentation of somatic dysfunction is.

The LCD Layer: Regional Variation Matters

There's no CMS National Coverage Determination (NCD) for OMT. Coverage instead runs through Local Coverage Determinations. UnitedHealthcare requires compliance with applicable LCDs and Local Coverage Articles (LCAs) where they exist.

This creates a two-track system. If your MAC has an LCD for OMT, that LCD governs — and UHC requires compliance with it. If you're in a state or territory with no applicable LCD, UHC falls back to its own internal criteria: medical necessity plus documented somatic dysfunction. Know which track applies to your region before billing.

Talk to your billing consultant or compliance officer if you're unsure which LCD applies to your service area. Getting this wrong means submitting claims under the wrong framework — and that produces denials that are harder to appeal.

Prior Authorization

This policy does not explicitly require prior authorization for OMT services. But prior auth requirements can vary by plan and market under Medicare Advantage. Verify authorization requirements at the plan level before scheduling high-volume OMT patients.

E&M and OMT: A Billing Distinction You Can't Ignore

E&M services are separately covered when medically necessary and appropriately documented. This is standard — but UHC is explicit about one important limit. No E&M service is warranted for a previously planned follow-up OMT visit unless a new condition arises or the patient's condition has changed substantially enough to require a full reassessment.

This is a real claim denial risk. If your practice routinely appends an E&M to every OMT visit, you're billing outside this policy's billing guidelines. Pull those claims and review.

UnitedHealthcare OMT Exclusions and Non-Covered Indications

The exclusion criteria here are straightforward. OMT is not covered when the medical necessity threshold isn't met and somatic dysfunction isn't documented in the medical record.

This isn't a lengthy exclusion list. It's one clear rule: no documentation, no coverage. The practical effect is that documentation gaps — not clinical judgment — are your primary denial risk. Underdocumented records are the functional equivalent of a non-covered service under this policy.

There's also no separate coverage for OMT as a standalone service divorced from a clinical indication. The treatment must address somatic dysfunction, defined as impaired or altered function of the somatic system — skeletal, arthroidal, and myofascial structures, along with related vascular, lymphatic, and neural elements. Document the connection between the clinical finding and the treatment explicitly.

Coverage Indications at a Glance

UnitedHealthcare OMT Billing Guidelines and Action Items 2025

The effective date is September 26, 2025. If you haven't already reviewed your charge capture and documentation workflows, do it now. Here's where to focus.

1. Audit your OMT documentation templates before billing after September 26, 2025.
Every OMT visit note must reflect TART findings — tenderness, asymmetry, restriction of motion, tissue abnormality. If your current templates don't prompt for these findings explicitly, update them. A check-box or structured note section for TART criteria is faster for providers and creates an auditable record.

2. Map your CPT code selection to documented body regions — exactly.
CPT 98925 covers one to two body regions. CPT 98926 covers three to four. CPT 98927 covers five to six. CPT 98928 covers seven to eight. CPT 98929 covers nine to ten. The code you bill must match the number of regions documented in the record — not the number treated informally. If the note says "lumbar and thoracic," bill 98926, not 98929.

3. Stop bundling E&M with routine follow-up OMT visits.
This is a specific billing guideline under this policy. E&M is separately billable only when a new condition occurs or the patient's status changes substantially enough to require full reassessment. Audit your recent claims for inappropriate E&M add-ons. If you find a pattern, address it before submitting additional claims — and consider whether any prior claims need review.

4. Verify which LCD applies to your service area.
Pull your MAC's current LCD for OMT (if one exists). UHC requires compliance with applicable LCDs under this policy. If your MAC's LCD has stricter criteria than UHC's internal coverage policy, the MAC LCD wins. Your billing team needs to know the floor before coding.

5. Update your ICD-10 linking logic for M99.00–M99.09.
Claims for CPT 98925 through 98929 must link to the correct ICD-10-CM code from the M99 range. Each code specifies the anatomical region. M99.01 is cervical. M99.02 is thoracic. M99.03 is lumbar. Make sure your charge capture links the right region-specific code to the right CPT — not a generic M99.09 for every claim.

6. If you're billing OMT for the somatic component of visceral disease, document that connection explicitly.
This policy covers OMT for the somatic component of visceral diseases — but the skeletal, arthrodial, and myofascial manifestations must appear in the record. A diagnosis of, say, irritable bowel syndrome doesn't justify OMT billing on its own. The somatic findings need to be there. If your practice treats this patient population, talk to your compliance officer about how to document these cases correctly.

CPT, HCPCS, and ICD-10 Codes for Osteopathic Manipulative Treatment Under osteopathic-manipulations-omt

Covered CPT Codes (When Medical Necessity Criteria Are Met)

Key ICD-10-CM Diagnosis Codes

One thing worth calling out on the ICD-10 side: M99.09 is your catch-all for abdomen and other regions, but it shouldn't be your default for every claim. Use the region-specific codes whenever the documentation supports them. Payers notice when practices consistently bill a vague category code instead of specific ones — it flags potential upcoding or sloppy documentation.

Also, somatic dysfunction in one region often drives compensatory dysfunction in adjacent regions. When that's the case clinically, document and code each affected region. Don't leave covered regions uncoded because it felt like one problem.