Recently, I was asked an interesting billing question many acupuncturists will be able to relate to. An acupuncturist who was new to billing had some concerns over how to bill. This acupuncturist had heard in addition to the acupuncture codes (97810-97814) that there was also a code to bill for the needles themselves.
What is this code and as is the correct way to bill? Other questions included: Can I bill four units of acupuncture if I spend one hour with the patient? Finally, I am also curious about how the ANSI 5010 format for billing will affect me? I heard it will change billing formats in 2012 and I have no idea what it is.
The first question is one that is often confused by many acupuncturists as there are codes for needles (A4215 needle, sterile, any size, each) however, it is appropriate for this code to be used for acupuncture services. Using needles is integral and essential to have acupuncture and as such needles are considered part of the service and not separately billable. In other words, the value of the needles is included in the charges for the overall service.
Specifically, the needless are considered "incident to" the acupuncture service. In billing for acupuncture you may bill for the sets of needles provided with codes 97810 initial set, manual, 97811 additional set(s) manual or 97813 initial set, electrical, and 97814 additional set(s) electrical. And, no separate coding for the needles themselves.
The needle code is used for the patient to take home and use for home injections like what a diabetic patient would use for insulin.
The latter question is often a confusing one as well as many acupuncturists may read the codes and place an emphasis on the aspect that indicates time. While the acupuncture codes are listed as 15 minutes face-to-face time one cannot ignore that it also requires additional needle(s) to qualify. If you were to spend time face-to-face with the patient, insert a set of needles, they rest on the needles for a period of time (even up to an hour or more) the code that can be billed would be for only one set. As 97811 or 97814 must have reinsertion of one or more needles. To bill for 4 units there would have to 4 separate insertions of sets of needles to qualify.
The American National Standards Institute (ANSI) 5010 may have no immediate impact on offices not billing insurance or billing electronically. ANSI 5010 is the new version of HIPAA transaction standards that regulates the electronic transmission of healthcare transactions. Meaning the format of and how electronic claims are formatted and transmitted to the carrier. This is covered under HIPAA of course as the transactions must be secure. This 5010 standards will replace the existing 4010/4010A1 version of HIPAA transactions as if creates a fix to the shortcomings in the current version, including that the current format does not support forthcoming ICD-10 coding.
In many ways these standards are clearing the way and standardizing health care information into one standard which will allow a universal electronic health record system that is compatible for all health care providers and payers. The goals are to:
Increase transaction uniformity
Support pay for performance
Streamline reimbursement transactions
Support ICD10 codification
The implementation of HIPAA 5010 has substantial changes in the data submitted as well as the data you receive in response to your electronic inquiries. The implementation may require changes to the software, systems, and perhaps procedures that you use for billing Medicare and other payers. However, in most but a few instances these changes are the responsibility and format used, but the clearinghouse and may require no or an update to your current software. The older your version of billing software the greater the possibility of a more complex and potentially costly upgrade.
Based on this it would be a good time to evaluate your current system and whether or not an upgrade is necessary and if so, and the cost is high it may be a benefit to change to a newer system that is online and has no costs for upgrades. There are several services for electronic billing that are no cost to the provider and are compliant with the 5010 standard. However, any change must be thought out thoroughly. For example, consideration must be made to patient information already in your current database being compatible and easily transferred or mapped to the new system. Also an online version of information only may mean when the system or Internet is down, you will have no access to your data.
For electronic billing under the 5010, the date of implementation is January 1, 2012. Testing should have been or is being done by all clearinghouses and software manufacturers to ensure compliant and correct by the January deadline.
It is likely you have already received information from your current software manufacturer or clearinghouse for needed updates. While updates may be necessary on the provider side they can be from very little or none, to almost a new system with the commensurate costs attached. If you have had no information from your software or clearinghouse vendor take it upon yourself to contact them and assure that you have all that is needed to be compliant and they transmitting your information in the correct manner by January.
This 5010 standard is also setting the groundwork for the universal use of Electronic Health Records (EHR) as it creates a standardization of how the records are encoded, shared, and transmitted. The implementation of EHR is currently not mandated (date is set for 2014). There is an incentive bonus paid to some providers who use EHR in 2012, but unfortunately acupuncturists are not part of that group. Only providers who may bill and are paid by Medicare can receive the bonus.
The ANSI 5010 also affects the use of the upcoming ICD-10 (October 2013 implementation). The ICD-10 implementation will allow for greater specificity in defining diagnosis. For instance there is designation of right and left as well as initial encounter to subsequent encounter. The ICD9 codes number about 13,000 while the ICD10 is 68,000 with codes all having alpha beginning and variations of 3-7 digits codes and procedure codes. The codes are much more specific in the ICD-10 implementations of ICD10 in European countries have indications that its use will lead to improved healthcare services at lower costs with fewer errors and improved results. It appears the ICD10 will offer a greater level of codes that may be used by acupuncturists.
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