Editor's note: The following is a portion of "Insurance 101, 2005 edition" article, which has been reprinted with Mr. Martin's permission. See the Oregon Acupuncture Association's website, www.oregonacupuncture.org, for the complete article, along with the following related articles:
Basic Information on Health Insurance Billing Codes and the New CPT Codes for Acupuncture
Healthcare Providers and Fees
Evaluation & Management Codes and How to Use Them (OAA News, Fall 2004)
Regence BCBSO Coverage for Acupuncture (OAA News, Fall 2004)
The provision of acupuncture and Oriental medicine within the third-party payor system of American health care necessitates the use of codes that designate what is being treated and what procedures are being utilized.
The codes that designate procedures are listed in Current Procedural Terminology (CPT), updated and published yearly by the American Medical Association. These codes cover everything from infrared to intracranial vessel surgery. Until 1997, there were no CPT codes for acupuncture, and therefore each payor designated their own codes, which they could change at will. The advent in that year of the CPT codes for acupuncture (97780) and acupuncture with electrical stimulation (97781) was a milestone for integration. Now we have a new milestone with the doubling of the acupuncture code set. As of January 1, 2005, 97780 and 97781 have been retired. In their place, we will have four new codes:
97810: Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97811: Acupuncture, one or more needles, without electrical stimulation, each additional 15 minute increment of personal one-on-one contact with the patient, with reinsertion. (List separately in addition to code for primary procedure.)
97813: Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97814: Acupuncture, one or more needles, with electrical stimulation, each additional 15 minute increment of personal one-on-one contact with the patient, with reinsertion. (List separately in addition to code for primary procedure.)
There cannot, of course, be milestones without obstacles, and the path of development for these new codes has been less than smooth. One glaring example of this is found in the definition of the codes, which includes the word "reinsertion." This is not a word that has meaning within the acupuncture community, since we do not reuse needles or points within a single treatment. This word was added by the RUC (see below) to connote an additional set of points that would demand a greater amount of work. A "set" is undefined, but according to the definition, it could be one point. It must, for documentation purposes, be distinctly separate in some fashion.
The CPT codes are the property of the AMA and serve as a significant source of income for that organization. The CPT codes are used nationwide and have become not only the de facto standard, but also the only HIPAA-compliant code set. HIPAA, amongst many other things, mandated that there be a consistent code set across the country. No longer would there be regional codes. No longer would individual payors be able to use their own codes. The Centers for Medicare and Medicaid Services (CMS) is responsible for contracting with the AMA and establishing what is essentially a government-mandated monopoly. An alternative code set, the Advance Billing Concept (ABC) codes, has been developed specifically with complementary and alternative medicine in mind. This was certainly not the focus of CPT. When HIPAA became the law of the land, there existed a certain amount of pressure on the CPT to expand the code set. Acupuncture was one area ripe for expansion.
The CPT Committee formed a workgroup comprised of representatives from the professional organizations that have acupuncture in their scopes of practice. These included the American Chiropractic Association (ACA), the American Academy of Medical Acupuncture (AAMA), the American Association of Oriental Medicine (AAOM) and the Acupuncture and Oriental Medicine Alliance (AOM Alliance). This group of practitioners met for over a year to develop a rational system that allowed for greater variability in coding an acupuncture treatment and still stood up under the scrutiny of, and was understandable to, the CPT Committee, few of whom had any knowledge of acupuncture. Time-based codes are something that has many precedents in the framework of the CPT code set, and the conclusion of the workgroup was that this was the best strategy for additional acupuncture codes. These codes were indeed accepted by the CPT Committee and were then sent to the Reimbursement Update Committee (RUC) for valuation. This process is one that all CPT codes through and is, as they say, "where the rubber meets the road."
Valuation of a code means establishing a number called a relative value unit (RVU) for that code. The number of "units" expresses a "value" which is "relative" to that of other procedures, whether they be a colonoscopy or a cold pack. The RVU is made up of three separate components. (The process of arriving at these values is beyond the scope of this article and to some extent proprietary to the AMA. Suffice it to say that it tries to be scientific, or at least systematic.) The "work value" denotes the training, effort and intensity of the practitioner's effort. The "malpractice value" denotes the risk involved in the procedure. The "practice expense value" denotes the cost of the office and equipment needed to perform the procedure. These three values are added to arrive at the RVU for that particular code. The RVU is then multiplied by a "conversion factor" to arrive at a dollar value for each code. The conversion factor is a dollar amount that is established contractually by insurers or regionally by CMS regulations for Medicare and Medicaid services. So, RVU x Conversion Factor = Reimbursement. The Medicare conversion factor for 2004 is $37.3374, which is one reason your physician colleagues have very mixed feelings about being involved in it.
The RVUs for all CPT codes are available online at www.cms.gov/regulations/pfs/2005/1429fc.asp -- download Addendum B. You can determine your own conversion factor by dividing the dollar amount of your charge for a particular procedure by that procedure's RVU. Which begs the question: What is the RVU for acupuncture? When 97780 and 97781 were established, there was disagreement amongst the practitioners consulted, and since neither code was a Medicare/Medicaid reimbursable expense, CMS did not feel it necessary to publish values. There do exist other RVU systems, which are published independently of CMS and the AMA, which did indeed publish values. Relative Value Studies Inc. published values of 1.83 for 97780 and 1.96 for 97781. If you go ahead and download Addendum B, you will see that our four new codes range in vale from .53 to .58. On the one hand, that's quite a drop in value, but if you look closely at Addendum B, you will notice that our new codes have no "practice expense value." That means that, through error or omission, the cost of actually having an office was left out of the code value. Any use of those code values by insurance companies without some adjustment for the omission is disingenuous at best, and a clear undervaluation of acupuncture services.
A review of similarly valued codes in Addendum B would suggest that the true RVU of our codes should range from .80 to 1.08, but we may never know. At this point, CMS is saying that they should not have published any value since acupuncture services are not reimbursable by Medicare/Medicaid, and that they will publish a correction early next year that will zero out all of the values for our new codes. The AMA is saying that the CPT RVUs are propriety information, and CMS is the only one who can publish them. In any case, you must establish your own values. I would only caution you not to undervalue your services, especially in the "practice expense" portion, if you bill any third parties.
The understanding of the workgroup is that the most common level of service would be 30 minutes of patient contact time; therefore, if there is no electrical stimulation, 97810 and one unit of 97811. If there is electrical stimulation in any part of the treatment, one would use 97813 and one unit of 97814. The CPT mandates that one cannot mix the acupuncture without electrical stimulation codes and acupuncture with stimulation codes. So, if you use electrical stimulation at any point in your treatment, you must use the electrical stimulation codes.
There are, of course, other nuances to code use. One of these is the aforementioned "reinsertion." Another involves evaluation and management (E&M). E&M codes are divided into a new and a returning patient series of five levels of increasing complexity, time and charge. New patient codes are 99201 through 99205. Established patient codes are 99211 through 99215. The difference between a new patient and an established patient is three years. If the patient has not been seen by anyone in your clinic in that amount of time, the patient can be considered "new." Specific definitions of these codes can be found in the CPT manual.
Historically, the profession of acupuncture has been based on a cash practice with little variation of charge from patient to patient. Moving toward integration into the reimbursement structure of American health care means adopting and adapting the standard practices of coding to what we do. Our responsibility is to charge with some consistency a reasonable amount for our services. Insurance is not a cash cow to be milked by the sophisticated practitioner, but an expression of the shared risk of human suffering. Typically within this model, one patient encounter would entail the use of one E&M code and one or more procedure codes. The new codes for acupuncture do have a small amount of E&M included, but it is minimal. The time element of the new codes is divided into three segments:
"Pre-service," greeting of the patient an a brief interval history. The code is based on this being three minutes.
"Intra-service," everything connected with doing the procedure - washing your hands, positioning the patient, locating and cleaning the points, inserting and stimulating the needles, checking on the patient, removing the needles. The code is based on this being 15 minutes. This does not include needle retention time when you are not directly monitoring or communicating with the patient.
"Post-service," charting and any instructions to the patient. The code is based on this being three minutes.
If your pre- and post-service time substantially exceeds six minutes, you could charge for a suitable level of E&M, but it is essential that you document that you have fulfilled the requirements of that E&M code, and you must modify the E&M code with a -25 modifier to denote that this is a significant, separately identifiable level of service. Strictly speaking, the modifier should only be needed with a 99211, but you may need to use it for all E&M codes. Insurers will expect E&M to be billed with a new patient and on re-evaluation or a new diagnosis of an established patient. Everything you code for must be supported by your chart notes.
Please see the full article, "Insurance 101, 2005 edition" at www.oregonacupuncture.org for useful information on chart notes (a.k.a. documentation) and E&M codes.