Neurology & Pain Management Coding Alert

Here’s how Medicare’s new acupuncture rules are playing out so far.

In 2020, Medicare made up its mind to start covering acupuncture for patients with a specific set of criteria. With 2021 just around the corner, experts are weighing in on how the new policy is progressing, and how to maximize rightful reimbursement on encounter forms.

The lowdown: Those in the know say you can get paid for acupuncture in certain situations — if you observe the rules Medicare made official in January.

Read on to see how to get your Medicare dollars for covered acupuncture services.

1 Condition Qualifies for Acupuncture

Medicare said it would cover acupuncture beginning in 2020, but that coverage is only for chronic low back pain (cLBP), confirms Toni Elhoms, CCS, CRC, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer, chief executive officer of Alpha Coding Experts, LLC, in the Orlando, Florida, area. “Also, there are strict NCD [National Coverage Determination] requirements to meet coverage criteria and Medicare only covers acupuncture for chronic low back pain,” explains Elhoms.

If the patient does have documented cLBP, “Medicare will cover up to 12 acupuncture sessions over the course of 90 days, as well as an additional eight sessions for patients who show improvement,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania. If a patient is showing improvement, they could be eligible for another eight sessions a year. “Medicare patients will be limited to no more than 20 acupuncture sessions a year. Treatment must be stopped if the patient shows signs that they are not improving or are regressing,” reminds Falbo.

The Centers for Medicare & Medicaid Services (CMS) defines cLBP as pain that:

• lasts 12 weeks or longer;
• is nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
• is not associated with surgery; and
• is not associated with pregnancy.

“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. Overreliance 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.”

Remember: These rules are for Medicare payers only. Elhoms reports that some third-party payers are reimbursing cLBP acupuncture services — but you should contact each non-Medicare payer individually, or check your contract, to see if it covers acupuncture for cLBP.

Report Acupuncture With This Code Quartet

If you are reporting acupuncture for cLBP, you’ll report one or more of the following codes, depending on encounter specifics:

• 97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
• +97811 … 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 … with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
• +97814 … 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)

ABN alert: You might consider obtaining a signed advance beneficiary notice (ABN) before performing acupuncture for cLBP patient, just in case Medicare doesn’t cover acupuncture for this patient. In cases where Medicare doesn’t always cover a service (such as acupuncture), an ABN is not required. Many practices do, however, provide an ABN or related information to the patient to advise the patient of their options for having the service and understanding any related financial obligations.

If you get a signed ABN on file for a patient before the acupuncture treatment, be sure to append modifier GA (Waiver of liability statement issued as required by payer policy, individual case) to the acupuncture code(s).

Know Who Can Provide Acupuncture

According to Falbo, physicians, physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), and auxiliary personnel can provide acupuncture if they meet their individual states requirements and have:

• A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and
• current, full, active, and unrestricted license to practice acupuncture in a state, territory, or commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.

Resource: Read more on Medicare’s acupuncture coverage at: www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295.