Billing for Additional Sets of Needles

Q: I have begun to bill insurance for my acupuncture services. While I am being paid for the first set of needles 97810 or 97813, I am having difficulty getting reimbursed for additional sets. How do you bill for additional sets? I am billing 97810 for the first set and then billing 97811 on two or maybe three additional lines for the added sets and they are never paid beyond the first 97811.

A: When billing for acupuncture there are four available CPT codes to describe the acupuncture services.

97810: Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with patient.

97811: Acupuncture without electrical stimulation, each additional 15 minutes of personal one on one contact with the patient, with re-insertion of needle(s) (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 patient.

97814: Acupuncture with electrical stimulation, each additional 15 minutes of personal one on one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure).

The codes that are for the initial set of needles, 97810 manual or 97813 electrical are billed once per visit at a maximum of one unit. Additional sets of needles, 97811 manual and 97814 electrical, may be billed in units based on the number of additional sets applied. On the bill itself, the codes 97811 or 97813 also only appear once, per date of service, but they may be billed in units according to the number of additional sets applied.

Never bill codes 97811 or 97814 more than once per date of service when providing three or more sets of needles. You would place that number of sets in block 24g of the 1500 form, to indicate the specific number of sets applied on that date of service. The total charge on that line of service would the number of units multiplied by the single-unit fee. For example if you charge $50 for 97811 and you did three units, the total charge on that line would be $150. You must do the multiplication and report the total on the line of service. If you put the single-unit price with three units, the assumption from the insurance company is that the actual price per unit is one-third of that and will pay the billed amount only. The insurance will not do multiplication of units and pricing so be sure that the total is the units multiplied the single unit price.

If you were to bill 97811 or 97814 on multiple lines for a single date of service in an effort to show the number of additional sets, the insurance carrier will deny the subsequent lines as a duplicate or error. This appears to be why you were not paid, as the sets beyond the second would be denied as you billed them on a separate line for the same date of service. As you noted, they will pay for the second set but never for any beyond that as the others were likely denied for the aforementioned reason.

This format of billing in units applies also to physical medicine and rehabilitation services that have a time component. This would include constant-attendance modalities 97035 to 97039 and therapeutic procedures 97110 to 97546. Of course, not all state acupuncture licensure allows use of physical medicine services. Therefore, the latter only applies to the those states that have a scope of practice that includes those specific services.

If you are having a hard time visualizing this format, send me an e-mail requesting the sample billing for multiple units of acupuncture services and I will forward to you a sample 1500 form with example of multiple units of acupuncture billing. Send your request to sam@aacinfonetwork.com.