Wiki Acupuncture 97810-97811: 1-on-1 contact with the patient

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CBLENNIE

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Good afternoon my AAPC peeps! If an acupuncturist spends about 5 minutes placing the needles (w/o e-stim) and then leaves the patient in the treatment room with a panic button and then returns after a predetermined amount of time, usually 15-20 minutes, does the time that the patient is alone in the treatment room count towards the time requirements of 97810 & 97811?

I have a provider who spends about 5 minutes placing the needles, then leaves the patient alone in the treatment room, then comes back after 15-20 minutes to remove the needles placed on the patient's front and then place needles on their back and then leaves the patient alone in the treatment room for another 15-20 minutes. The provider wants to bill 1 unit of 97810 and 2 or 3 units of 97811 (depending on whether the patient is booked for a 45- or 60-minute appointment).

I'm questioning whether or not the time requirements are being met to bill so much time for these visits since the code description in Encoder Pro states 1-on-1 contact with the patient without mention of whether or not the patient can be left unattended, and the practitioner can be out of the room doing whatever else they are doing during the day. Am I overthinking this???
 
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Hi there, from the CPT manual:
Acupuncture is reported based on 15-minute increments of personal (face-to-face) contact with the patient, not the duration of acupuncture needle(s) placement.
Click to expand...
 
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No, the time the patient is left unattended is not personal, face-to-face, one-on-one contact, it is unattended...
What is the provider doing when they leave? Trying to get credit for one-on-one contact with multiple patients at the same time in different treatment rooms being left unattended?
Red flag audit warning all over this scenario.

Example info/answer: https://www.uhcprovider.com/content...omm-reimbursement/COMM-Acupuncture-Policy.pdf

Questions and Answers Q: When selecting the appropriate code based on the services performed, is it appropriate to use the duration of time the patient is in the exam room even if the provider is not present after the needle insertion to determine the units of service? A: No, Acupuncture code selection is based on the service provided in 15 minute increments. The time calculation is determined using face-to-face patient contact only. It would not be appropriate to count time spent away from the patient as part of the code selection and units submitted. Example of billable time: After needle insertion, the practitioner spent time assisting a nauseous patient who had vomited.

This is the same idea as a PT trying to bill 97110 for multiple patients at the same/overlapping time. Or, while doing an eval with a patient while a different patient is doing ther ex. with an aide and billing all of it at the same time.
 
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I don't know what she is doing while she is out of the treatment room, but it appears she only has one patient booked at a time. She does all of the patient communications herself, mostly via text, so she may be using the time she is out of the room contacting patients and other admin tasks. For a patient's first appointment that lasted exactly 60 minutes she billed the commercial insurance plan 99203-25 x1, 97810 x 1, 97811 x 2 & 97026-GP. Her new patient paperwork barely takes up 1 page and she doesn't do much of a HPI with the patients, she just looks at the info and then verifies the areas/conditions the patient is seeking treatment for and then starts placing the needles. I don't see how she could get a 99203 out of this, aside from the fact that I don't think she is able to bill for the E&M in the first place.

Her version of infrared therapy is this heat lamp that she puts over a patient's feet or back when they have needles in their feet or to keep them warm, that doesn't seem right to me. She billed a commercial insurance company $330.00 for this new patient visit but if the patient had been a cash pay patient it would've been a flat $85.00 for a 1-hour appointment. She as also billed for 97016-Application of a modality to 1 or more areas; vasopneumatic devices, for what appears to be cupping as she does not have a vasopneumatic device that I've seen.

I think there is something very fishy with what is being billed to insurance here. She is contracted with our local Blue PPO plan and I'm planning on confirming whether her contract allows her to bill the 99203-25 & 97026. I'm considering reporting her to the Blue plan for possible abusive billing practices but I want to have my ducks in a row before I do so.
 
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I agree with @jkyles - this is something you should discuss with her before reporting her. This could be entirely unintentional. In my experience, many providers who have had to do their own coding and have not had access to a coder for education often get their information from odd sources that aren't reliable. She may simply not understand what she's doing or may have received bad advice about how to code. Also keep in mind that if any incorrect coding is not actually causing significant overpayments (for example if the plan is denying the E&M visits as Medicare would for this type of provider), then there's potentially no harm done anyway. Most providers want to do the right thing, so best to give them the chance to do so.
 
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100% agree, don't jump to conclusions and jump straight to that. You have to speak with the provider, management, practice superiors first.
 
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