Pain Management Coding Alert

Proposal would allow for narrow-scope study.

After all these years, there might have been a few holes punched in Medicare’s heretofore impenetrable policy against covering acupuncture services.

Details: “The Centers for Medicare & Medicaid Services (CMS) proposed to cover acupuncture for Medicare patients with chronic low back pain who are enrolled participants either in clinical trials sponsored by the National Institutes of Health (NIH) or in CMS-approved studies,” according to a July CMS release.

Read on to see how this might affect coding at your PM practice.

Opioid Crisis Has Led to Acupuncture Study

Examining the efficacy of acupuncture to treat chronic pain is partially a result of the evolution in the practice, and partially because of the opioid crisis that has overwhelmed parts of the country this decade.

“Defeating our country’s epidemic of opioid addiction requires identifying all possible ways to treat the very real problem of chronic pain, and this proposal would provide patients with new options while expanding our scientific understanding of alternative approaches to pain,” said Health and Human Services (HHS) Secretary Alex Azar in a release.

CMS reports that it also “recognizes that the evidence base for acupuncture has grown in recent years, but questions remain.”

Experts are patiently waiting to see how this proposal plays out.

“I think it would be a while before [acupuncture] would make it to being actually covered. In my opinion, I think it’s a step in a much-needed direction,” says Cathy Satkus, CPC, coder at Harvard Family Physicians in Tulsa, Oklahoma. “I think if there are findings that it really helps it does stand a chance of coverage.”

Proposal Employs Specific Eligibility Rules

The proposal announces that during the proposed trial, CMS would “continue its collaboration with NIH to further develop evidence to inform future Medicare coverage determinations for acupuncture treatment for beneficiaries with chronic low back pain,” according to a press release.

“Chronic low back pain impacts many Medicare patients and is a leading reason for opioid prescribing,” said CMS Principal Deputy Administrator of Operations and Policy Kimberly Brandt. “Today’s proposed decision would provide Medicare patients who suffer from chronic low back pain with access to a nonpharmacologic treatment option and could help reduce reliance on prescription opioids.”

Medicare: Falling Behind Private Payers?

While Medicare currently provides no coverage for acupuncture, more private payers are covering it in some form, says Satkus. “Due to the opioid addiction crisis I think there would be backlash if it helps and insurances don’t cover it.”

To wit: Some of the BlueCross BlueShield plans cover acupuncture, while some payers offer discount programs for it, explains Satkus. 

Aetna already has a policy for acupuncture as stated below:

Aetna considers needle acupuncture (manual or electroacupuncture) medically necessary for any of the following indications:

• Chronic (minimum 12 weeks duration) neck pain; or 
• Chronic (minimum 12 weeks duration) headache; or
• Low back pain; or
• Nausea of pregnancy; or
• Pain from osteoarthritis of the knee or hip (adjunctive therapy); or 
• Postoperative and chemotherapy-induced nausea and vomiting; or
• Postoperative dental pain; or
• Temporomandibular disorders (TMD).

To read the proposed decision, visit the CMS website at:  https://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=295.

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