How to bill insurance for acupuncture

how to bill insurance for acupuncture

New CPT Code for Acupuncture

Information from American Medical Association (AMA)

Acupuncture Code and corrections

●97810 Acupuncture, one or more needles,; without electrical stimulation;, initial 15 minutes of personal one-on-one

contact with the patient

+●97811 each additional 15 minutes of personal one-on-one contact with the patient,with

re-insertion of needle(s) (List separately in addition to code for primary procedure)

(Use 97811 in conjunction with 97810)

(Do not report 97810, 97811 in conjunction with 97813 or 97814)

(Evaluation and Management services may be reported separately, using the modifier 25, if the patient’s condition requires a

significant separately identifiable E/M service, above and beyond the usual preservice and postservice work associated with

the acupuncture services. The time of the E/M service is not included in the time of the acupuncture service.)

●97813 Acupuncture, one or more needles,; with electrical stimulation;, initial 15 minutes of personal one-on-one contact

with the patient

+●97814 each additional 15 minutes of personal one-on-one contact with the patient with

re-insertion of needle(s)

(List separately in addition to code for primary procedure)

Revise codes 97810 and 97813 with the movement of the semi-colon following ‘needles’, to follow ‘stimulation.’

New CPT Code for Acupuncture

- News from AAOM November 2004

After almost two years of work, a coalition led by the American Association of Oriental

Medicine that included the American Chiropractic Association, the American Association of Medical Acupuncturists, and the

AOMAlliance, succeeded in updating the CPT codes for acupuncture. This was a long and difficult process. Many thanks to

Roger Brooks and Gene Bruno of the AAOM and to the representatives of the other organizations who helped us obtain

these codes.

The new codes are:

97180 Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact

with the patient.

97811 each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion(note) of needles.

97813 Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with

the patient.

97814 each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles.

(Please buy the 2004 CPT book to get a complete list of codes and descriptors).

Note: The use of the term “re-insertion” does not mean that we should violate sterile technique and re-insert the same

needles. The term reflects the intention of the CPT committee that the additional 15 minute period(s) of acupuncture include

location, marking and cleaning points, hand-washing, insertion, manipulation, removal and disposal of needles. In other

words, the additional 15 minute period(s) reflect the work value of performing acupuncture.

There are two differences between the current codes and the new codes:

1. One difference is that the new codes allow for reporting and reimbursement of acupuncture or electroacupuncture in

15-minute increments. We were previously limited to one increment of acupuncture (or electroacupuncture) reimbursement

per visit. Now, in more complex cases, we can bill for additional time in 15-minute increments. (There is no limit as to the

number of 15-minute increments in the CPT book however you must be able to document the medical necessity of each

service with your SOAP notes).

2. The other difference is that the procedures of the acupuncture or electroacupuncture were previously not defined in

terms of their work value, therefore the insurance industry had no basis for deciding how much to pay for our services. In

defining the “relative unit value”, we provide a basis for insurance carriers to compare our work to that of other health

providers and pay us accordingly. By describing the “work” of acupuncture (including the level of skill required, the difficulty

and risks involved), and then breaking that work into timed increments similar to physical therapy or other timed codes, we

can expect to rise with the tide when other timed services increase in value. This way, we do not fight alone against the

insurance companies.

What does “15-minutes” mean?

It is very important to note that “15 minutes” is defined as “personal one-on-one contact with the patient”. This means that

you are not only in the room with the patient, you are actively performing a medically necessary activity that is a component

of acupuncture or electroacupuncture. The time that the needles are retained is specifically excluded for reimbursement.

“Personal one-on-one contact with the patient” does not mean hanging out with the patient and talking about their 5-element

preferences or their love life for that matter. We don’t get paid for counseling under these codes. We don’t get paid for

evaluation and management of the patient under these codes except for the “usual preservice and postservice work

associated with the acupuncture services”. These codes are for performing the procedures of acupuncture or

electroacupuncture, not for the initial history and exam or subsequent re-examination (more on this later). You can think of

this as the time your hands are doing some component of the acupuncture service.

“Personal one-on-one contact with the patient” is limited to; selecting, locating, marking and cleaning the points, washing your

hands, inserting and manipulating the needles, removing and properly disposing the needles. The only exception to this is in

the case of a patient who must be continuously monitored. An example is a patient who is nauseated and may vomit at any

time. If you must be on hand to remove the needles during the course of treatment, you may count that as face-to-face time.

Another example would be a patient who is getting distal acupuncture for an inflammatory joint condition like sciatica (Yao

Tong Xue) or bursitis

of the shoulder (St. 38), and you are directing the patient to move while the needles are in place to

enhance and evaluate the effectiveness of the treatment. Or, perhaps you are treating someone with low blood pressure and

you must monitor the pulse so that you can suddenly remove the needles to avoid fainting.

Evaluation and Management

You are also being paid to provide the “usual preservice and postservice work associated with the acupuncture services” that

accompanies a repeat visit. The usual preservice work means that you greet the patient, take an interval history, i.e. “How

have you been since your last visit?” and re-examine any positive findings from your initial exam that you need to monitor to

adjust your treatment (such as rechecking tongue and pulse). At the end of the acupuncture or electroacupuncture, you chart

what you did and any instructions you gave to the patient. This is the usual postservice work. In other words, the level of

effort that goes into performing the activities reflected in SOAP notes is included in the work value of these codes. The

preservice and postservice times are expected to be about 3 minutes each.

When the patient has suffered a significant new trauma or change in symptoms, or if 4-6 weeks have passed and you feel you

need to perform a re-examination to monitor the effectiveness of treatment, you may (if your scope allows) perform a re-

examination and bill an Evaluation and Management code (i.e. Office visit). It is not appropriate to bill an office visit with

every acupuncture treatment.

How long should the treatment take?

Based on our survey, we think that the average treatment will be two units of time, with one or three units being less

common. No one is suggesting that you use a stopwatch and note the times in your patient chart, but if you are treating 20

patients a day, it would be ridiculous to claim that they all received an hour of your undivided attention.

Please don’t change your clinical procedures to maximize your reimbursement. Do what you normally do to achieve the best

clinical result and charge what you think your services are worth. Whatever you do, document your care in your SOAP

notes. In the case of a dispute, you must have good SOAP notes to make your case that the time you spent was medically

necessary). Medical necessity is not documented simply by listing a lot of points. You must show that the patient had

subjective complaints and objective findings that required treatment to the points you selected. The CPT supplement has

examples of treatments and how to code them. You can buy that from the AMA.

Electroacupuncture and Acupuncture Together

The CPT book doesn’t allow you to bill for a “mix and match” of acupuncture and electroacupuncture on the same visit. This

is to prevent acupuncturists from charging for inserting the needles (acupuncture) and then attaching electrodes to those same

needles (electroacupuncture). The insurance industry does not want to pay twice for inserting the same needles. To prevent

that confusion, they simply set up the codes so that you will only be reimbursed for billing either units of acupuncture or units

of electroacupuncture, not both. So what do you bill if you perform an initial 15 minutes of electroacupuncture and a second

15 minutes of acupuncture without electrical stimulation? You bill both as electroacupuncture. As inaccurate as it appears, the

relative unit committee decided that this is the best way to handle the issue. The differential in reimbursement for the

additional period of acupuncture versus electroacupuncture is small enough to be the lesser of two evils in the eyes of the

relative unit committee.

How much will I be paid?

This question cannot be answered. Insurance companies will determine what they think is fair. In the case of HMO’s, the

payment is by contract, so the new codes may not have much effect. Some carriers may decide that they will only pay for

one increment of service in a day. Some may decide not to pay you at all. If your patients are as unhappy as you are about

your reimbursement, they may advocate on your behalf. You may decide not to accept insurance reimbursement from

carriers who are too restrictive.

What is the relative unit value of our services?

The work value of a 15-minute acupuncture treatment is .60. This compares with the work value of .21 for 15 minutes of

ultrasound. This is an excellent valuation for our services and represents a real triumph for the profession. Because our codes

are now timed, our work value will rise with the tide as other professions fight to increase reimbursement for their services.

Additional 15 minutes of acupuncture has a work value of .55. Electroacupuncture is valued at .65 and additional

electroacupuncture is valued at .60. The additional time codes do not include additional pre- and postservice time. It is

assumed that the additional periods of insertion do not require additional pre- and postservice work.

How much should I charge?

Regardless of the new CPT codes or Relative Unit Values assigned to these codes, you must decide what your services are

worth. Neither the AMA nor the insurance industry is setting your fees by assigning a work value to your services. You set

your fees based on your own business needs and what the average cash-paying patient is willing to pay for your services. In

other words, it is the free market, not the insurance company that determines the value of your services.

David Wells, D.C. L.Ac.

AAOM Insurance Committee


Category: Insurance

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