Wiki Acupuncture services to Medicare

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Biller2023

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We have a patient who comes to us every week for an acupunture service and feels better when he get this service. It looks like medicare only covers up to 20 visits in a 11 month rolling period and after the 20th visit they deny all acupuncture services until the next 11 month period begins. We use acupuncture codes 97810 (1 unit) 97811 (2 units) and 97813 (1 unit) 97814 (2 units). From the 12th to the 20th visit, medicare requested to include modifier KX with these codes which we have been doing and we do not have issues getting paid until the 20th visit.
As this patient comes to us every week, how can we make medicare make payments even after the 20th visit. I tried appealing with progress notes showing medical necessity but they have still denied the appeal and sent us the attached letter. Can someone please let me know what add on code we need to use as mentioned on this letter and what we should also mention in the office notes so medicare pays even after the 20th visit. Thank you.
 
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Athlete2023 said:
We have a patient who comes to us every week for an acupunture service and feels better when he get this service. It looks like medicare only covers up to 20 visits in a 11 month rolling period and after the 20th visit they deny all acupuncture services until the next 11 month period begins. We use acupuncture codes 97810 (1 unit) 97811 (2 units) and 97813 (1 unit) 97814 (2 units). From the 12th to the 20th visit, medicare requested to include modifier KX with these codes which we have been doing and we do not have issues getting paid until the 20th visit.
As this patient comes to us every week, how can we make medicare make payments even after the 20th visit. I tried appealing with progress notes showing medical necessity but they have still denied the appeal and sent us the attached letter. Can someone please let me know what add on code we need to use as mentioned on this letter and what we should also mention in the office notes so medicare pays even after the 20th visit. Thank you.
Click to expand...

That's a benefit limit - there isn't coverage for more than that.

If the patient would like to receive this service weekly, have you considered having the patient sign an ABN to pay out of pocket for the visits beyond the limit?

Here's a CMS tutorial on how that would work when you'd provide more than the number of services allowed in a specific period:

Advance Beneficiary Notice of Non-coverage Tutorial - MLN909183

Advance Beneficiary Notice of Noncoverage Tutorial
www.cms.gov
 
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Athlete2023 said:
We have a patient who comes to us every week for an acupunture service and feels better when he get this service. It looks like medicare only covers up to 20 visits in a 11 month rolling period and after the 20th visit they deny all acupuncture services until the next 11 month period begins. We use acupuncture codes 97810 (1 unit) 97811 (2 units) and 97813 (1 unit) 97814 (2 units). From the 12th to the 20th visit, medicare requested to include modifier KX with these codes which we have been doing and we do not have issues getting paid until the 20th visit.
As this patient comes to us every week, how can we make medicare make payments even after the 20th visit. I tried appealing with progress notes showing medical necessity but they have still denied the appeal and sent us the attached letter. Can someone please let me know what add on code we need to use as mentioned on this letter and what we should also mention in the office notes so medicare pays even after the 20th visit. Thank you.
Click to expand...
Hi there, I don't see an attached letter but in general you can't "make" Medicare pay for a service once you pass the frequency limit. In some cases you can appeal but that isn't an option once you hit the 20 treatment mark for acupuncture. You'll need to tell the patient that if they want additional services before the next period they will have to pay out of pocket. The patient can decide whether or not they want to pay.
 
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jkyles said:
Hi there, I don't see an attached letter but in general you can't "make" Medicare pay for a service once you pass the frequency limit. In some cases you can appeal but that isn't an option once you hit the 20 treatment mark for acupuncture. You'll need to tell the patient that if they want additional services before the next period they will have to pay out of pocket. The patient can decide whether or not they want to pay.
Click to expand...

That's my understanding as well.

The benefit is 12 visits with the possibility of an additional 8 visits. 20 visits would already include the additional 8 that could be allowed for medical necessity.
 
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For some reason it does not let me attach the letter. It says a server error occured. Please try again later. The letter suggests to bill with an add on code

Is there an email where I can send the letter via email?
 
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I read the letter. It is telling you:

1) The patient has had 20 visits in a 12-month period and no more visits can be granted.

2) The progress notes also don't support medical necessity, because the patient has a zero out of ten on the pain scale.

3) The add-on service can't be considered when the primary code it corresponds with is denied.

4) The patient cannot be billed for these services.

For future visits, you should discuss with the patient whether they want to continue with the visits by paying out of pocket, and have the patient sign an ABN.

If you've never used an ABN before, you'll want to follow the instructions in this tutorial: https://www.cms.gov/Outreach-and-Ed.../ABN-Tutorial/formCMSR131tutorial111915f.html

If the patient signs an ABN and you bill Medicare for future services, you'll also want to use the appropriate ABN modifier. ABN modifiers are GA, GX, GY, and GZ. Here's an explanation of what those modifiers mean:


Also, here's a link to the Medicare National Coverage Determination relating to Acupuncture for Chronic Low Back Pain if you need further information on why it isn't covered:

 
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