By David Wells, DC, LAc, Member, AAOM Insurance Committee
Greetings, colleagues! After almost two years of work, a coalition led by the American Association of Oriental Medicine (AAOM) that included the American Chiropractic Association, the American Academy of Medical Acupuncture, and the Acupuncture and Oriental Medicine Alliance, succeeded in updating the current procedural terminology (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:
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 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 2005 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.
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.)
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), 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 five-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 pre-service and post-service 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 pre-service and post-service work associated with the acupuncture services" that accompanies a repeat visit. The usual pre-service 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 re-checking the 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 post-service 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 pre-service and post-service 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 HMOs, 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 .50. Electroacupuncture is valued at .65 and additional electroacupuncture is valued at .55. The additional time codes do not include additional pre- and post-service time. It is assumed that the additional periods of insertion do not require additional pre- and post-service 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.
CPT Codes: Questions and Answers
Following you will find questions, answers and comments that will clarify some of the points raised about the new CPT codes.
Q: Do these codes begin in January?
A: Yes, you must use the new codes as of Jan. 1, 2005.
Q: Do we have to purchase new Superbills?
A: Yes. However, you may use the Superbills you have and write the new codes into the optional code slots if you have them.
Q: I have the 2004 CPT book as you suggested in your update. I see no changes to acupuncture codes, as listed on page 295. Did you mean 2005? When do they actually go into effect?
A: The changes are in the 2005 book, which is on sale now.
Q: Thanks to you and the committee members who worked hard on the code changes.
A: You are welcome. I would like to note that Roger Brooks, LAc, chaired the committee that obtained these codes. He did so under the guidance of Gene Bruno, LAc. I reported to Roger and Gene. Without them, this would never have happened. Your membership in the AAOM helped achieve this victory as your dues helped with airfare and conference call expenses. The American Chiropractic Association should also get a lot of credit, as their experts, Tony Hamm, DC, Christine Goetz, DC, and Craig Little, DC, guided us through the process. You may be surprised that the chiropractors were involved, but they were the ones who helped us get the original acupuncture and electroacupuncture codes in 1998. I was the only acupuncturist at that AMA Relative Unit Committee (RUC) meeting. I was a guest of the American Chiropractic Association. The chiropractors have a seat at the RUC table. We also had support from Marshall Sager, MD, and Jim Dowden of the AAMA, and Peter Martin, LAc, of the Alliance. I don't want this to appear as if I did all the work. Many people, supported through your dues, made this happen.
Q: Why was no mention made of also being able to charge for other separate services we perform under our scope of practice in addition to acupuncture or electroacupuncture (such as moxa, cupping and tuina?)
A: This article was about the new codes we obtained. Other codes, such as massage therapy, which may be part of your scope of practice, were not mentioned. You can see all the codes in the AMA's 2005 CPT Codebook. As to the implied question of why we didn't try to get other codes specific to our art, believe me, we thought hard about many possibilities. Bear in mind that our existing acupuncture and electroacupuncture codes were due to expire at the end of 2004. If we did not succeed in getting those reinstated, we would have no way to bill. If we over-reached, we may not have ended up with any code at all. Furthermore, the existing codes did not have a work value. Establishing a work value is a labor-intensive process. Every code we obtained came at a high cost. A lot of time, energy and money went into getting these codes. We certainly wanted, and still want, more and better codes. We will keep working on this. Please understand that we have to make our case to a committee of the American Medical Association. This committee is comprised of our economic competitors. Many of them see our gain as their loss.
Q: My understanding is that we don't have specific codes for moxa, cupping and tuina. Is that true?
A: Only the California workers compensation system has codes for moxibustion and cupping. Together with DaRen Chen, LAc, Kevin McNamee, DC, LAc, and members of the National Board of Acupuncture Orthopedics, I helped obtain those codes in 1992. Those codes only applied to the California workers compensation system.
In the late 1990s, while I was medical director of Landmark Healthcare, I introduced those same codes in the states where Landmark was doing business (about 19) but that only applied to patients whose insurance was administered by Landmark. Other insurance companies may not know those codes. I used my position at Landmark to try to get the moxibustion and cupping codes into general use. Landmark's competitor followed our example and used similar codes in the states where they do business. Those of you who are covered by contract with any HMO using those codes may have the ability to bill for those moxibustion and cupping codes under the terms and conditions specified by that HMO. You know who you are.
Q: What are our chances of getting codes for tuina, cupping and moxa? Also, this is a national change, reflected in the AMA's CPT coding, correct?
A: As far as tuina goes, when I was medical director of Landmark, we used to allow LAcs to bill tuina as 97140. This code is used primarily by physical therapists for joint mobilization or myofascial release. Scope of practice issues and the definition of tuina must be clarified in most states before there is widespread use of this code by acupuncturists. A specific tuina code would face significant opposition from chiropractors and physical therapists. We could conceivably try to amend the definition of 97140 to include the word tuina. I will explore this possibility, but the PTs are likely to block it.
As to cupping, I have not seen any research that proves safety or efficacy for this modality. It is also not in as widespread use as acupuncture or electroacupuncture. Remember, we needed the help of the DCs and MDs to get our codes passed. If they are not also doing cupping, it would be harder to document on our own that there is enough use to warrant a cupping code. I do believe that we have a chance at getting a moxibustion code, though in my searches of Medline, I have found almost nothing for moxa, and there are significant safety issues, so this is certainly not a cakewalk. I think that moxibustion offers our best chance at a new code despite these hurdles. If we do apply for a moxibustion code, it will have to be indirect moxa because of the safety issue. The requirements for new codes include the following:
The procedure must have evidence of safety and effectiveness printed in main line peer-reviewed journals such as the Journal of the American Medical Association or the New England Journal of Medicine. Research performed in Asia generally does not meet the quality standards.
The procedure must be performed a significant number of times in the United States. This is best documented by insurance billings, though it can be estimated.
About two years of work and politics to get the codes adopted.
This is a national change. If we obtain coverage through Medicare, these codes will be used. Without these codes, we would never be able to obtain coverage through Medicare. The AMA creates and publishes these codes for the benefit of Medicare and other insurers.
Q: As a comparison, what is the relative value code for massage in 15-minute intervals?
A: Fifteen minutes of massage (97124) is has a work value of .35 compared to a work value of .60 for the initial 15 minutes of acupuncture.
Q: Would it be possible to provide a follow-on article business operating changes for implementation in the practitioner's office?
A: Please send specific questions and I will answer them as well as I can.
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