CAM, Acupuncture, and Medicare

Becky Buegel, RHIA, CDIP, CHP Outpatient Coding Leave a Comment

CAM, Acupuncture, and Medicare

CAM? Isn’t she some female American country music singer/songwriter?

No – a CAM is a rotating or sliding piece in a mechanical linkage that has something to do with turning rotary motion into linear motion – at least that’s what the dictionary said. Besides, what would have female country music singer or a car engine part have to do with acupuncture? Well, they have absolutely nothing to do with acupuncture – unless the singer has acupuncture treatments! In this instance, CAM stands for “Complimentary and Alternative Medicine.” What’s that you ask? CAM is the term used to describe medical therapies that are not part of standard or traditional medical care. While many different types of therapies fall under the term Complimentary and Alternative Medicine – such as naturopathy, homeopathy, massage therapy, and acupuncture, to name just a few, most insurance companies will not cover CAM treatments. There are some health insurance providers that WILL cover treatments like acupuncture under certain circumstances. And, believe it or not, as of January 21, 2020 even Medicare, yes, Medicare covers acupuncture as noted below.

Let’s begin by defining acupuncture. Acupuncture is a form of traditional (think “old”) Chinese medicine. The practitioner (acupuncturist) uses long, thin, sterile needles to stimulate specific body points, with the intent to promote the body’s natural healing processes. Clinical studies have shown that it can effectively treat conditions such as neck and back pain, anxiety, depression, insomnia, infertility, chronic fatigue, cancer, and much more. Clearly, acupuncture is growing in acceptance as a viable medical treatment.

 

Medicare and Acupuncture

Traditional Medicare Part B covers up to 12 acupuncture treatment in 90 days for chronic low back pain (ICD-10-CM code M54.50). An additional 8 additional sessions are covered if the patient shows improvement, with the maximum per year being no more than 20 total treatments. The catch, however, is that the there must be improvement in the pain; if it isn’t improving or if it worsens, Medicare will not cover the 8 additional treatments.

 

Medicare Conditions for Coverage

  • Chronic low back pain is defined as:
    • Lasting 12 weeks or longer
    • Having NO KNOWN cause
    • Pain not associated with surgery or pregnancy
  • Treatment must be provided by a doctor in accordance with applicable state requirements, OR
  • Another health care provider such as an NP; PA; Clinical Nurse Specialist; or auxiliary personnel (under adequate supervision) who meet applicable State requirements and who has both:
    • A masters or doctoral degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine; AND
    • A current, full, active, and unrestricted license to practice acupuncture in the State, Territory, or Commonwealth in the US or District of Columbia.

 

Other Coverage and/or Self-Pay

The Veterans Administration has been providing acupuncture services for the last 5 or so years, and acupuncture can be a covered benefit for some insurance companies as well. More often than not, patients wanting acupuncture must pay for the treatments out-of-pocket – AKA “self-pay.” Depending on the individual plan, some commercial insurance companies that may provide acupuncture coverage include:

  • Aetna
  • Banner Health
  • BCBS
  • Health Net
  • United Healthcare

 

No Matter the Payer, Accurate Coding Means Accurate Reimbursement

It goes without saying, that accurate treatment documentation is the foundation for accurate coding. Keep in mind the importance of medically necessity when documenting the services provided.

 

In Conclusion

Medicare WILL now pay for acupuncture IF correct CPT and ICD-10-CM codes are used! Become familiar with and follow the rules! 

MEDICARE-COVERED ACUPUNCTURE TREATMENT CODES

Acupuncture services are always billed in 15-minute increments. Use one code for the initial 15 minutes of service, and then a separate code for additional units of time. The current rules cover the following acupuncture treatment codes at the current Medicare national average fee schedule.

CPT Code

Description

Definition

97810

Initial Acupuncture

Initial 15-minute, personal one-on-one contact with the patient, with insertion of one or more needles, without electrical stimulation. Not to be reported with 97813; use one or the other.

97811

Subsequent Unit of Acupuncture

Use one unit per each additional 15 minutes of personal one-on-one contact with the patient after the initial 15 minutes, with reinsertion of needles. May be used in conjunction with either 97810 or 97813.

97813

Initial Acupuncture with

Electrical Stimulation

Initial 15-minute, personal one-on-one contact with the patient, with insertion of one or more needles, with electrical stimulation. Not to be reported with 97811; use one or the other.

97814

Subsequent Unit of Acupuncture with Electrical Stimulation

Use one unit per each additional 15 minutes of personal one-on-one contact with the patient after the initial 15 minutes, with reinsertion of needles. May be used in conjunction with either 97810 or 97813.

20560

Insertion of Needle into Muscle Trigger Point for Injection of Therapeutic Agent

Needle insertion(s) without injection(s) of 1 or 2 muscle(s)

20561

Insertion of Needle into Muscle Trigger Point for Injection of Therapeutic Agent

Needle insertion(s) without injection(s) of 3 or more muscles

 

For Additional Information Related to the Above Codes See:

https://www.cms.gov/newsroom/press-releases/cms-finalizes-decision-cover-acupuncture-chronic-low-back-pain-medicare-beneficiaries?utm_ campaign=Acupuncture&utm_source=hs_email&utm_medium=email&_hsenc=p2ANqtz-_O_DA99cXa-INhqMASEZ0813fKhShY8-ztk3HTPhE3xK8ENBlC7zr013EijumSaQXDCa3c

https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=295

https://www.cms.gov/files/document/mm11755-national-coverage-determination-ncd-3033-acupuncture-chronic-low-back-pain-clbp.pdf

https://www.cms.gov/medicare-coverage-database/view/ncd.aspx? ncdid=373&ncdver=1

 

SUMMARY

Medicare now covers up to 20 acupuncture treatments on the condition that the treatments are provided only for chronic low back pain and that the recipient shows improvement in the pain level. Other specific conditions for coverage apply.

 

ADDITIONAL INFORMATION/LINKS:

https://www.va.gov/WHOLEHEALTH/docs/AcupunctureFactSheet_508.pdf

https://www.cms.gov/files/document/mm11755-national-coverage-determination-ncd-3033-acupuncture-chronic-low-back-pain-clbp.pdf

 

KEY WORDS:

Acupuncturea form of ancient Chinese medicine involving pricking the skin or tissues with needles, used to treat pain and various physical, mental, and emotional conditions.

CAM – Complimentary and Alternative Medicine – medical therapies that are not part of traditional medical care.

Chronic Low Back Pain pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without sciatica; defined as chronic when it persists for 12 weeks or more.

Leave a Reply

Your email address will not be published. Required fields are marked *

Sign Up For MRA Blog Updates!

Recent Posts