Q: I have gotten a request for a refund of money from Blue Cross, stating that I coded my acupuncture services improperly. I am not sure they are accurate about my coding having an error and that any refund is due.I coded for my acupuncture services with 97810 (manual acupuncture, initial set) and 97813 (electro-acupuncture, initial set). As a general protocol I perform both manual and electroacupuncture on each visit. Is this not the correct way to code for that type of service?
A: I have had several of these inquiries in the last month. Blue Cross Blue Shield is beginning to audit acupuncture claims for accuracy. When it is found that there is invalid coding, Blue Cross Blue Shield is seeking reimbursement for the incorrectly coded services. Per your example of billing 97810 and 97813 on a single visit, coding of those two items at the same visit is incorrect. Both codes indicate an initial set of needles, and there cannot be more than one initial set. Any second set up of acupuncture needles on the same visit is coded with the specific codes for an additional set (97811 or 97814) on the same visit. 97810 and 97813 cannot be reported on the same visit or encounter.
The correct coding would have been to code either 97810 or 97813, depending on which was the first set of needles used, electric or manual. The additional or second set would have been 97811 or 97814 for manual or electric acupuncture, additional set. You may indeed mix manual with electro-acupuncture and can use a combination in any manner simply based on what was specifically done. For example when the first set was electrical 97813 and the second set on the same visit was manual, it would be coded with 97811. If additional sets were done, the 97811 can be billed in multiple units.
Therefore, the review by Blue Cross Blue Shield was indeed correct. However, it is not that the patient did not get the acupuncture services but simply the coding of the additional set of needles was improper. Therefore it is not an issue of a refund of the full amount of a code but a refund of the difference between the value of the correct code versus the code that was billed and paid.
Assuming the initial set of needles was electrical (97813), it would therefore be payable with no refund due for that service. However, the second set, assuming it was manual, should have been coded 97811 and not 97810. Therefore, the value difference between 97811 and 97810 would need to be refunded. The general difference in value between the two codes is 97811 is about 66 percent or two-thirds the value of 97810. Consequently, the amount due would be approximately one-third the amount paid for 97810.
Bear in mind this error should in no way constitute fraud but was simply a coding error, as there were services provided. Review your chart notes to determine which acupuncture service was performed first and which was second. Once the appropriate code for the second set is determined, account for the number of dates billed. Then multiply the number of dates with the difference in the amount. In general, the difference in fee for an initial set of needles 97810 or 97813, compared to a second set 97811 or 97814 is about one-third less for the second set. Therefore, it is not the full value of the code initially billed but likely only one-third of what was reimbursed for that specific code.
My experience with Blue Cross Blue Shield is that they understand that the services were done but simply improperly coded. They are open to negotiation of the amount to be repaid and may allow installments, as noted in my example. This is not a guarantee of such but based on recent experience with them in matters of this nature.
The lesson here is to be aware of your coding and ensure the billing is correct. Errors on our end can result in refunds; though certainly do not assume the carrier is correct in noting the error. Review the coding to ascertain who or what is correct and further verify the specific amounts, as the initial requests do not necessarily take into account the offset. In my opinion, Blue Cross Blue Shield should have caught this error on the initial review and not paid for one of the codes. In that sense, we would not owe a refund but would have to review and recode to be paid for the second set as it would have initially been denied for payment.
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