Maximizing Insurance Reimbursement For Acupuncture Services

Billing insurance for acupuncture requires knowledge of the correct CPT and ICD codes. CPT codes are billing codes, while ICD codes are diagnosis codes. CPT codes for acupuncture services are always coded in 15-minute increments, with separate codes for the initial 15 minutes of service and additional units of time. It's important to use the correct codes to avoid claim rejections and delays in payments, which can impact revenue and business operations. Acupuncture providers should also be aware of modifiers, which provide additional information about the claim and can affect reimbursement. Understanding billing procedures and staying up-to-date with any changes are crucial for effective insurance billing for acupuncture services.

CPT and ICD codes

CPT (Current Procedural Terminology) codes are standardized numeric codes used to describe medical procedures and services provided by healthcare professionals. They are used to document the majority of medical procedures performed by healthcare providers and enable providers to properly bill insurance companies and receive reimbursements for administered services.

Acupuncture CPT codes are categorized by the three main sources of revenue for your practice: acupuncture treatments, office visits, and physical therapy-based treatments and modalities.

97810 - Initial acupuncture without electrical stimulation (first 15 minutes)

97811 - Subsequent unit of acupuncture without electrical stimulation (additional 15 minutes)

97813 - Initial acupuncture with electrical stimulation (first 15 minutes)

97814 - Subsequent unit of acupuncture with electrical stimulation (additional 15 minutes)

For office visits, CPT codes for evaluation and management (E/M) services can be billed for the initial patient evaluation and follow-up evaluations. CPT codes 99201-99204 can be used for new patients, while 99211-99214 are used for established patients.

Physical therapy-based treatments and modalities may include tendon injections (20550, 20551), muscle injections (20552, 20553), therapeutic exercise (97110), neuromuscular reeducation (97112), manual therapy (97140), massage therapy (97124), and kinetic activities (97530).

ICD (International Classification of Diseases) codes, on the other hand, are used to classify diagnoses, symptoms, and medical conditions. They help identify specific diagnoses or conditions for which acupuncture treatments are provided, enabling acupuncturists to seek reimbursement from health insurance providers.

G89.0 - Central pain syndrome

G89.11 - Acute pain due to trauma

G89.12 - Acute post-thoracotomy pain

R52 - Other acute pain

G89.21 - Chronic pain due to trauma

G89.28 - Other chronic post-operative pain

M79.6 - Myalgia (muscle pain)

M54.2 - Neck pain

M54.3 - Sciatica

M54.4 - Low back pain

M54.6 - Thoracic spine pain

H92.0 - Ear pain

H57.1 - Eye pain

R68.84 - Jaw pain

R07.0 - Throat pain

Billing for office visits

For established patients, E/M services can be billed for periodic follow-up evaluations (every 30 days or every sixth visit) using CPT codes 99211 to 99214. An established patient is defined as someone who has received professional services from you or another provider of the same specialty within the past three years. It is not appropriate to bill these codes every time a patient receives acupuncture treatments, as acupuncture CPT codes 97810, 97813, 97811, and 97814 include evaluation and management done as part of the overall daily treatment.

The initial examination and follow-up examinations (about once every four weeks) require modifier -25 to indicate that the evaluation done on the particular visit is above and beyond the one associated with the acupuncture service.

The CPT codes for established patients are as follows:

99211 Evaluation/Management (Minimal)

Presenting problems are minimal. The provider typically spends five minutes face-to-face with the patient.

99212 Evaluation/Management (Limited)

Presenting problems are self-limited or minor; requires a problem-focused history, a problem-focused examination, and straightforward decision-making. The provider typically spends 10 minutes face-to-face with the patient.

99213 Evaluation/Management (Expanded)

Presenting problems are of low to moderate severity; requires an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity. The provider typically spends 15 minutes face-to-face with the patient.

99214 Evaluation/Management (Detailed)

Presenting problem(s) are of moderate to high severity; requires a detailed history, a detailed examination, and medical decision-making of moderate complexity. Providers typically spend 25 minutes face-to-face with the patient.

It is important to note that billing with incorrect CPT and ICD codes can lead to claim rejections and delays in payments, which can negatively impact revenue generation and the sustainability of your business.

Acupuncture treatment codes

Acupuncture treatments are coded in 15-minute increments. The first 15 minutes of service are coded differently from successive units of time. Acupuncture CPT codes only differ if electronic stimulation is used as part of the therapy.

The four most important Acupuncture CPT codes are:

97810: Initial acupuncture without electrical stimulation. This code is used for the initial 15-minute needle insertion and one-on-one contact with the patient.

97811: Acupuncture subsequent unit without electrical stimulation. This code is used after the initial 15 minutes. It covers each additional 15 minutes of personal one-on-one interaction with the patient, including needle re-insertion.

97813: Initial acupuncture with electrical stimulation. This code covers the initial 15-minute needle insertion and one-on-one contact with the patient.

97814: Acupuncture subsequent unit with electrical stimulation. This code is used for each additional 15 minutes of one-on-one contact with the patient, including needle re-insertion.

It is important to note that every insurance provider can decide which codes they will reimburse, and this may vary from provider to provider. Therefore, it is crucial to understand the correct CPT codes and billing methods to ensure a smooth payment process and attain the full financial potential of your practice.

Evaluation and Management (E/M) services

For acupuncture office visits, or E/M services, there are specific billing guidelines. E/M services can be billed on the initial patient evaluation with CPT codes 99201 to 99204. For periodic follow-up evaluations, CPT codes 99211–99214 can be used, but these are typically billed every 30 days or every sixth visit. It is important to note that incorrect CPT and ICD codes can lead to claim rejections and delays in payments, which can impact revenue.

The E/M standards and guidelines were established by Congress in 1995 and revised in 1997. They have been adopted by private health insurance companies as the standard guidelines for determining the type and severity of patient conditions. This allows medical service providers to document and bill for reimbursement for services provided.

Medical record documentation is an essential component of E/M services. It records pertinent facts, findings, and observations about an individual's health history, including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record also facilitates communication among healthcare professionals, accurate and timely claims review, and collection of data for research and education. Payers may request information to validate the site of service, the medical necessity, and appropriateness of the services provided.

The CPT codes for E/M services have specific descriptors that correspond to the procedure or service provided. These codes are typically five digits and can be numeric or alphanumeric, depending on the category. The CPT code set is regularly updated by the CPT Editorial Panel to reflect current clinical practice and innovation in medicine.

Reimbursement rates

When billing for acupuncture services, it is important to use the correct CPT (Current Procedural Terminology) codes and ICD (International Statistical Classification of Diseases and Related Health Problems) codes. CPT codes are billing codes, while ICD codes are diagnosis codes. The correct use of these codes is essential to avoid claim rejections and delays in payment.

The CPT codes for acupuncture services are 97810, 97813, 97811, and 97814. These codes are time-based and account for the total time spent with the patient and the type of procedure applied. The initial 15 minutes of insertion of needles and personal one-on-one contact with the patient are billed using code 97810. Subsequent 15-minute increments of personal one-on-one contact with the patient, with re-insertion of needles, are billed using code 97811. If electronic stimulation is included in the treatment, the appropriate codes are 97813 for the initial 15 minutes and 97814 for each additional 15 minutes.

It is worth noting that the reimbursement rates for these new codes are generally higher than the previous rates, except for the first two years of implementation, where a miscalculation in the time-reimbursement value led to underpayment by insurance carriers.

In terms of insurance coverage for acupuncture, it is inconsistent, and insurers that do cover it often impose strict limits. Some public and private insurance plans cover certain acupuncture treatments, with varying coverage details. For example, Medicare Part B covers acupuncture for chronic low-back pain, with a limit of 12 sessions in 90 days, and allows for 8 more sessions if the patient's condition improves. Aetna added acupuncture as a standard benefit for various health conditions in 2022. BlueCross Blue Shield of Massachusetts covers 12 sessions per year, after which a 30% discount kicks in. Kaiser Permanente offers acupuncture coverage for nausea, pain, and other disorders, with up to 20 visits per year and a $15 copay.

Additionally, some states are gradually adopting acupuncture as an essential health benefit that must be covered by private health insurance policies sold within the state. For example, Oregon requires health insurance sold in the state to cover 12 acupuncture sessions per year, while Colorado's essential health benefits will include 6 acupuncture visits per year starting in 2023.

Frequently asked questions