Medicare Compliance & Reimbursement

Caution: Review provider restrictions to avoid denials.

If acupuncture services are on your radar as a helpful offering to alleviate your patients’ pain, you’ll be excited to know that Medicare will now reimburse for the treatment option.

Then: Last July, the Centers for Medicare & Medicaid Services (CMS) proposed adding acupuncture to its list of covered services as an alternative to opioids for managing lower back pain (see Medicare Compliance & Reimbursement, Vol. 45, No. 14).

Now: On Jan. 21, CMS released a National Coverage Determination (NCD) change and will now pay for acupuncture services, indicates an NCD memo.

The agency points to several reasons for moving to cover the service for back pain sufferers, suggesting that acupunctures’ benefits far outweigh its harms. At the top of its reasoning to add this treatment option is medical research and evidence that show acupuncture diminishes pain and improves function, a CMS release suggests.

It’s also a great alternative to opioid use for pain and aligns with the federal efforts to reduce prescriptions of the oft-abused drugs, according to CMS. Plus, many private payers already cover acupuncture services and the agency aims to keep current with industry standards, the release says.

“Expanding options for pain treatment is a key piece of the Trump Administration’s strategy for defeating our country’s opioid crisis,” said HHS Secretary Alex Azar in a release. “Medicare beneficiaries will now have a new option at their disposal to help them deal with chronic low back pain, which is a common and sometimes debilitating condition.”

See the Coverage Logistics

However, for Medicare to cover the services, providers and their patients must meet certain criteria. There are three things that factor into the coverage and include training and certification, diagnosis, and a treatment timeline.

See if your training and patients’ conditions match the CMS requirements for acupuncture services:

1. Provider overview: If you are a physician, physician assistant, nurse practitioners/clinical nurse specialist, or auxiliary medical staff (under supervision) and have a masters or doctoral degree in acupuncture or Oriental Medicine from an institution accredited by the Accreditation Commission of Acupuncture and Oriental Medicine (ACAOM), you may provide the service, details the NCD memo. Your license must also be “current, active, and unrestricted to practice acupuncture” in the states or territories you offer services in.

2. Patient checklist: According to the NCD memo, Medicare will cover the care for beneficiaries with chronic lower back pain (cLBP) and defines the condition with these specific parameters:

• The back pain lasts 12 weeks or longer;
• is not related to any other “identifiable systemic cause,” disease, etc;
• is not from surgery; and
• is not caused by pregnancy.

3. Length of treatment: If your patients meet the cLBP criteria and your certifications match the accreditation requirements, then Medicare will cover 12 visits over 90 days “with an additional 8 sessions for those patients with chronic low back pain who demonstrate improvement,” the release says.

“We are dedicated to increasing access to alternatives to prescription opioids and believe that covering acupuncture for chronic low back pain is in the best interest of Medicare patients,” said Kimberly Brandt, CMS principal deputy administrator of operations and policy in a release. “We are building on important lessons learned from the private sector in this critical aspect of patient care. Over-reliance on opioids for people with chronic pain is one of the factors that led to the crisis, so it is vital that we offer a range of treatment options for our beneficiaries.”

Resource: Read more on the NCD change at  www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295.