Billing Aetna Insurance For Acupuncture Services: A Guide For Practitioners

Acupuncture is a form of complementary or alternative medicine that is utilized to treat pain, stress, and other physical and emotional conditions. As such, it still lacks widespread acceptance, especially by insurance companies. However, as more and more people get relief with acupuncture, demand for the treatment rises.

Aetna covers acupuncture in both new and recurring commercial health plans in which recipients meet certain criteria. In 2022, Aetna added acupuncture as complementary health treatment coverage to provide recipients additional options for chronic pain relief.

Acupuncture treatments are generally covered through Aetna when the procedures are deemed medically necessary. Treatments must also be performed by healthcare providers who are practicing acupuncture within the scope of their medical licenses.

Conditions that Aetna usually considers medically necessary pertaining to acupuncture treatment include:

- Chronic back or neck pain (12-week minimum duration)

- Nausea from pregnancy

- Pain caused by knee osteoarthritis

- Temporomandibular (TMD) disorders

Experimental acupuncture treatments aren't usually covered by Aetna because they're not considered medically necessary. Some examples of conditions that fall under the experimental acupuncture category per Aetna guidelines include:

- Carpal tunnel syndrome

- Post-traumatic stress disorder

Billing and coding

When billing for acupuncture services, it is important to follow the correct billing and coding guidelines.

Evaluation and Management (E/M) Coding

Evaluation and Management (E/M) codes are used to report services that include:

• History
• Examination
• Medical decision-making

The Current Procedural Terminology (CPT) codes for E/M services are divided into two categories:

• Office or other outpatient services (99202-99215)
• Hospital observation services (99217-99220)

The level of E/M service is determined by:

• History
• Examination
• Medical decision-making

Acupuncture CPT Codes

The CPT codes for acupuncture services are:

• 97810 - Acupuncture, without electrical stimulation, with 1 or more needles; initial 15 minutes of personal one-on-one contact with the patient
• 97811 - Acupuncture, without electrical stimulation, with 1 or more needles; 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)
• 97813 - Acupuncture, with electrical stimulation, with 1 or more needles; initial 15 minutes of personal one-on-one contact with the patient
• 97814 - Acupuncture, with electrical stimulation, with 1 or more needles; 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)

ICD-10-CM Codes

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is a system used to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease.

The ICD-10-CM codes for acupuncture services are:

• M84.81 - Acupuncture therapy
• M84.82 - Acupressure
• M84.83 - Acupotomy
• M84.84 - Electroacupuncture
• M84.89 - Other acupuncture technique

When billing for acupuncture services, it is important to follow the correct billing and coding guidelines. Here are some key guidelines to keep in mind:

• Use the appropriate CPT and ICD-10-CM codes for acupuncture services.
• Ensure that the services provided meet the medical necessity criteria for acupuncture.
• Follow the correct coding guidelines for E/M services.
• Bill for acupuncture services using the appropriate CPT and ICD-10-CM codes.

Medical necessity

Medical Clinical Policy Bulletins (CPBs) are used by Aetna to determine what services and procedures are considered medically necessary, cosmetic, or experimental and unproven. CPBs are based on peer-reviewed, published medical journals, reviews of available studies, evidence-based consensus statements, expert opinions of health care professionals, and guidelines from nationally recognized health care organizations.

Aetna's determination of medical necessity is made on a case-by-case basis and is dependent on the specific details of a member's benefit plan. Medical necessity is decided based on whether a service or supply is deemed appropriate and necessary for the diagnosis or treatment of a member's condition, disease, or injury. Aetna's conclusion that a particular service or supply is medically necessary does not guarantee coverage, as the member's benefit plan ultimately determines coverage.

Aetna's Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients requiring evaluation and treatment for behavioral health conditions. The ABA Medical Necessity Guide does not constitute medical advice, and treating providers are solely responsible for medical advice and treatment of members.

In the event that a member disagrees with a coverage determination, they may be eligible for an internal appeal and/or an independent external appeal in accordance with applicable federal or state law.

Aetna coverage

Aetna covers acupuncture in both new and recurring commercial health plans in which recipients meet certain criteria. In 2022, Aetna added acupuncture as complementary health treatment coverage to provide recipients additional options for chronic pain relief.

Acupuncture treatments are generally covered through Aetna when the procedures are deemed medically necessary. Treatments must also be performed by healthcare providers who are practicing acupuncture within the scope of their medical licenses. Conditions that Aetna usually considers medically necessary pertaining to acupuncture treatment include:

• Chronic back or neck pain (12-week minimum duration)
• Nausea from pregnancy
• Pain caused by knee osteoarthritis
• Temporomandibular (TMD) disorders

Experimental acupuncture treatments aren't usually covered by Aetna because they're not considered medically necessary. Some examples of conditions that fall under the experimental acupuncture category per Aetna guidelines include:

• Carpal tunnel syndrome
• Post-traumatic stress disorder

Some Aetna plans may limit coverage for recipients who opt for acupuncture instead of anesthesia for dental or surgical procedures, but other plans may provide additional coverage. Specific coverage can vary by plan, so it's important for Aetna recipients to verify their specific coverage benefits with a plan representative.

Aetna billing

Aetna covers acupuncture in both new and recurring commercial health plans in which recipients meet certain criteria. In 2022, Aetna added acupuncture as complementary health treatment coverage to provide recipients additional options for chronic pain relief.

Aetna covers acupuncture when the procedures are deemed medically necessary. Treatments must also be performed by healthcare providers who are practicing acupuncture within the scope of their medical licenses. Conditions that Aetna usually considers medically necessary pertaining to acupuncture treatment include:

• Chronic back or neck pain (12-week minimum duration)
• Nausea from pregnancy
• Pain caused by knee osteoarthritis
• Temporomandibular (TMD) disorders

Experimental acupuncture treatments aren't usually covered by Aetna because they're not considered medically necessary. Some examples of conditions that fall under the experimental acupuncture category per Aetna guidelines include:

• Carpal tunnel syndrome
• Post-traumatic stress disorder

Some Aetna plans may limit coverage for recipients who opt for acupuncture instead of anesthesia for dental or surgical procedures, but other plans may provide additional coverage. Specific coverage can vary by plan, so it's important for Aetna recipients to verify their specific coverage benefits with a plan representative.

Documentation Requirements

Acupuncture should be provided in accordance with an ongoing, written plan of care. The purpose of the written plan of care is to assist in determining medical necessity and should include the following:

• The diagnosis along with the date of onset or exacerbation of the disorder/diagnosis
• A reasonable estimate of when the goals will be reached
• Long-term and short-term goals that are specific, quantitative and objective
• Acupuncture evaluation
• The frequency and duration of treatment
• The acupuncture protocol to be used in treatment

Signatures of the patient's attending physician and/or acupuncturist

The plan of care should be ongoing, (i.e., updated as the member's condition changes), and treatment should demonstrate reasonable expectation of improvement (as defined below):

Acupuncture services are considered medically necessary only if there is a reasonable expectation that acupuncture will achieve measurable improvement in the member's condition in a reasonable and predictable period of time.

The member should be reevaluated regularly, and there should be documentation of progress made toward the goals of acupuncture.

The treatment goals and subsequent documentation of treatment results should specifically demonstrate that acupuncture services are contributing to such improvement.

The above policy is based on the following references:

• Aetna
• American Academy of Medical Acupuncture (AAMA)
• National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM)
• American Medical Association (AMA)

Aetna documentation

Aetna considers acupuncture (manual or electroacupuncture) medically necessary for any of the following indications:

• Chronic (minimum 12 weeks duration) neck pain
• Chronic (minimum 12 weeks duration) headache
• Nausea of pregnancy
• Pain from osteoarthritis of the knee or hip (adjunctive therapy)
• Post-operative and chemotherapy-induced nausea and vomiting
• Post-operative dental pain
• Temporomandibular disorders (TMD)

Aetna covers acupuncture in both new and recurring commercial health plans in which recipients meet certain criteria. In 2022, Aetna added acupuncture as complementary health treatment coverage to provide recipients additional options for chronic pain relief.

Aetna covers acupuncture when the procedures are deemed medically necessary. Treatments must also be performed by healthcare providers who are practicing acupuncture within the scope of their medical licenses.

Aetna may cover acupuncture for certain indications, such as various forms of pain, nausea, and migraine headaches.

Aetna may cover acupuncture for nausea and pain when administered by a physician.

Aetna also offers discounts for additional conditions not covered by insurance. You can use your HSA/FSA for acupuncture regardless of whether insurance covers the treatment.

Frequently asked questions