Acupuncture Billing and Reimbursement
Acupuncture insurance billing procedures are on the move. For an acupuncturist, the key is to follow changes in CPT codes and ICD codes. CPT codes are billing codes and ICD codes are the diagnosis codes. The current list of billing codes under the existing ICD-9 structure will change under the new ICD-10 structure. The new system is due to be implemented in October of 2015. That said, the due date for the switch has been pushed back several times already and may face further delays in implementation. As for billing codes, insurance companies have added some interesting new twists to their use. Let's take a look at the particulars and then some unfortunate, if not outright unsettling, trends in the health insurance industry. Learn special details in the HealthCMi acupuncture continuing education course entitled Acupuncture Billing #1.
Most insurance companies only accept pain related diagnostic codes for acupuncture and Chinese Medicine. Other commonly accepted diagnoses include nausea due to chemotherapy and morning sickness and codes for the treatment of temporomandibular dental related disorders. Occasionally, acupuncturists may be able to bill for asthma, fatigue, dizziness and vision disorders. However, the use of ICD-9 codes for these disorders may get rejected by the insurance carriers. Ultimately, standards for insurance are regulated on a state by state basis and are determined on a policy by policy basis.
There are six remaining states where acupuncture performed by a licensed acupuncturist is technically not legal. In other states such as California, Washington, Oregon, New York and Massachusetts, acupuncture is highly regulated. However, insurance standards vary tremendously and the procedures allowed by a licensed acupuncturist also vary greatly. The shift from ICD-9 codes to ICD-10 codes, however, will affect all acupuncturists in all states. The ICD system is international and will impact acupuncturists in Canada, Australia and other countries. ICD stands for the International Statistical Classification of Diseases and Related Health Problems. ICD-10 will be the 10th revision of the diagnosis codes and will include 7 digits whereas the existing ICD-9 system includes 5 digits. This will allow for greater specificity of ailments.
To implement the new changes an acupuncturist needs to simply purchase the new ICD-10 book and use the new diagnosis codes when sending bills to the insurance company or when generating superbills. Some acupuncture insurance billing software companies will automatically update the codes and other software will require the manual addition of the new codes. In addition, the use of the ICD-10 system may coincide with increasing demands for online submission or paperless submission of billing forms. The use of paper forms such as the CMS/HCFA 1500 will eventually be phased out but it looks like the next year or two will allow for paper bills. Expect software packages such as MacPractice, Compulink and other major players in EHR (Electronic Health Records) to automatically update all billing codes and allow for continuing electronic billing. To learn more about ICD-10 codes and how to use them in an acupuncture clinic, visit the web page: Acupuncture ICD-10 Insurance Billing Codes Made Easy.
Several years ago, there were two acupuncture billing codes. One code was used for electroacupuncture and the other for acupuncture. They have been replaced by four codes. The 97810 code is for the application of acupuncture. Technically, it is for the application of one or more acupuncture needles during the initial phase of an acupuncture treatment wherein the acupuncturist has “personal one-on-one contact with the patient.” The next code, 97811 is for each additional 15 minutes of acupuncture during that same treatment period. However, the code stipulates that there is a “re-insertion of needles” for it to be allowed.
There has been a buzz in the acupuncture community over the term “re-insertion” since it may imply taking a needle out and putting it back in again. That would be a violation of clean needle technique and several state laws. OK, not the best choice of words. Either additional acupuncture needles must be added to the patient after the first 15 minutes for the 97811 code to be used or re-insertion may imply the use of acupuncture techniques such as Setting the Mountain on Fire, Penetrating Heaven’s Coolness and other procedures that involve lifting and thrusting of the needles. If the latter is true, then the code may not acknowledge the Dragon and Tiger Fighting technique and other procedures based on twirling the needle. Clarification would be helpful in the CPT system.
The next two codes are similar to the acupuncture codes only they account for the additional time and effort in the application of electroacupuncture. The 97813 code is for the first 15 minutes of electroacupuncture and the 97814 code is for the next 15 minutes of electroacupuncture, again with “re-insertion” as a requirement. That’s the technical jargon, but what about the actual reimbursement rates?
The new codes are time based. They account for the total time with the patient plus the type of procedure applied. Historically, the implementation of these new codes accompanied greater reimbursement rates with the exception of the first two years of implementation. A miscalculation in the time-reimbursement value of the new acupuncture billing codes caused an across-the-board underpayment by many insurance carriers. The mistake was caught within about two years but acupuncturists never received back compensation. In addition, it was legally determined that the insurance companies were under no obligation to pay the acupuncturists although they were underpaid. Further, the new ICD-10 system may entirely replace the existing CPT codes. For now, the CPT/HCPCS codes remain.
Today, there are insurance carriers that will only pay the first code and will ignore any additional timed codes. Other carriers pay a percentage of each code billed. In some cases, carriers will pay the entire amount billed. This is a difficult situation for the licensed acupuncturist. Let’s look at an example of a $75 office visit. If one performs a 45 minute acupuncture visit and divides their standard fee into thirds for each portion of the visit and bills 97810 at $25 and bills two 97811 codes at $25 each, the insurance carrier may only recognise the first code and will pay according to a $25 cost per visit. On the other hand, some carriers will pay based on a $75 acupuncture visit. If an acupuncturist bills $50 for the initial 15 minutes and $12.50 twice with the next two 15 minute codes, the acupuncturist runs into similar difficulties. Some insurance carriers will discount reimbursement for the first 15 minutes because of the addition of extra codes. Ultimately, it is the first 15 minutes that is weighted most heavily for reimbursement by the CPT system and that is where the bulk of the fee is best placed in most scenarios.
Another trouble encountered by licensed acupuncturists is underpayment when adding physiotherapy CPT codes. Legally, acupuncturists are allowed to use these codes but insurance companies may wind up paying for these codes and ignoring the acupuncture codes entirely. These codes include 97110 for therapeutic exercises, 97112 for neuromuscular reeducation, 97114 for functional activities, 97540 for training of activities of daily living, 97610 for soft tissue mobilization, etc….
An example would be the application of tui-na, shiatsu or another form of massage that is billed with the 97610 code. One would expect that adding additional time for the application of massage would yield a higher reimbursement rate. Unfortunately, insurance carriers often either ignore the code and pay the acupuncture codes or they ignore the acupuncture codes and pay the physiotherapy codes while at the same time dinging the patient’s annual allotment for physical therapy by one visit. Yes, in some cases insurance carrier will pay for all of the services rendered and billed. Some premium insurance plans continue to reimburse providers based on the actual services rendered. Patients with these plans tend to be in high technology or are union members.
Disturbing But Legal
There are two very disturbing acupuncture insurance reimbursement issues. One is a new twist and the other is an old fine print issue. The new twist is in common use by at least one major insurance carrier. Patients are allotted a limited number of acupuncture treatments per year and a deductible. As in many cases, only a small dollar amount is applied towards the deductible per each acupuncture visit and not the true cost of the acupuncture visit. Nothing new you say? Oh yes, here’s the best part. Every acupuncture office visit counts towards the total visits per year allowed. If the patient receives enough acupuncture treatments to reach their deductible, they have already long exceeded the total number of treatments per year allowed. It is not mathematically possible that the insurance carrier will be required to pay for a single dollar towards acupuncture treatment. In the past, the total number of treatments allowed per year was calculated after the deductible had been met. In the new twist, the number of acupuncture treatments per year allowed is counted from day one. The patient or the patient’s company is sold an insurance package that contains acupuncture benefits but the patient and acupuncturist will never receive, under any permutation or combination, any reimbursement.
The good news is that in some states such as California, the number of visits per year may not be capped for patients with individual plans or small group plans. This new protection starts in 2014 in the State of California. It is part of the state’s implementation of regulations required by Obamacare, the Patient Protection and Affordable Care Act. In fact, both California and Maryland are extending acupuncture health insurance coverage to all of its citizens with small group and individual health insurance plans.
I mentioned another problem with health insurance coverage for acupuncture that is found deep within the fine print of a major HMO acupuncture contract. It is the old body part shell game. If a patient receives their allotment of care for a particular body part, they may no longer receive healthcare benefits for the same body part until after a specified amount of time. For example, say a patient is treated for low back pain due to a new injury. The insurance carrier may reject acupuncture reimbursements because that patient has received other care for the lower back within a two year period. This applies even if the care rendered two years ago pertained to a separate injury. Although this insurance industry practice is legal, it is morally suspect. All that said, most insurance carriers do not stoop to this level of absurdity.
The ultimate strategy for a fair and balanced method of providing acupuncture insurance benefits for patients involves contacting the insurance carrier. It is very time intensive. It requires verifying coverage with the carrier and hoping that the information is accurate. Legally, the insurance companies cannot be held to the information provided. Also, the phone calls required to attain verification of acupuncture benefits can easily exceed twenty minutes per patient. In some cases, the wait time may be significantly longer. The dream scenario would be a standardized online form across all health insurance plans wherein the patient or provider can login and simply view the benefits in an easily recognisable fashion.
Providing health insurance benefits for patients requires either a significant amount of time on the acupuncturist’s behalf or it involves hiring staff to handle the complexities of getting paid. The cost is always there. Either an acupuncturist sacrifices time or incurs a significant expense in an effort to provide health insurance coverage for patients. So, what is the true cost of health insurance? Apparently, premiums are only the beginning of the actual costs.