FOR THE FIRST TIME, THE CPT BOOK 2005 INCLUDES CODES FOR ACUPUNCTURE
SERVICES!
Continuing a trend of creating CPT codes for allied health professionals,
such as Osteopathic Manipulation Codes and Chiropractic Manipulation Codes
in previous editions, the American Medical Association has added CPT codes
for Acupuncture to CPT 2005. In addition to the new Acupuncture codes,
there are numerous additions and deletions to CPT 2005. According to CMS
guidelines, the 2005 edition codes must be reported for services rendered
on or after January 1st of this year. The 90-day grace period for reporting
expired codes has been eliminated, so you may not report deleted codes on
or after January 1st.
AAOM Report on CPT Acupuncture Codes
After almost two years of work, a coalition led by the American
Association of Oriental Medicine that included the American Chiropractic
Association, the American Association of Medical Acupuncturists, and the AOMAlliance, succeeded in updating the CPT codes for
acupuncture. This was a long and difficult process. Many thanks to Roger
Brooks and Gene Bruno of the AAOM and to the representatives of the other
organizations who helped us obtain these codes.
The new codes are:
97180 Acupuncture, one 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(note) of needles.
97813 Acupuncture, one or more needles, with electrical stimulation,
initial 15 minutes of personal one-on-one contact with the patient.
97814 each additional 15 minutes of personal one-on-one contact with the
patient, with re-insertion of needles.
(Please buy the 2004 CPT book to get a complete list of codes and
descriptors).
Note: The use of the term “re-insertion” does not mean that
we should violate sterile technique and re-insert the same needles. The
term reflects the intention of the CPT committee that the additional 15
minute period(s) of acupuncture include location, marking and cleaning
points, hand-washing, insertion, manipulation, removal and disposal of
needles. In other words, the additional 15 minute period(s) reflect the
work value of performing acupuncture.
There are two differences between the current codes and the new codes:
1.
One difference is that the new codes allow
for reporting and reimbursement of acupuncture or electroacupuncture
in 15-minute increments. We were previously limited to one increment of
acupuncture (or electroacupuncture) reimbursement
per visit. Now, in more complex cases, we can bill for additional time in
15-minute increments. (There is no limit as to the number of 15-minute
increments in the CPT book however you must be able to document the medical
necessity of each service with your SOAP notes).
2.
The other difference is that the procedures
of the acupuncture or electroacupuncture were
previously not defined in terms of their work value, therefore the
insurance industry had no basis for deciding how much to pay for our
services. In defining the “relative unit value”, we provide a
basis for insurance carriers to compare our work to that of other health
providers and pay us accordingly. By describing the “work” of
acupuncture (including the level of skill required, the difficulty and
risks involved), and then breaking that work into timed increments similar
to physical therapy or other timed codes, we can expect to rise with the
tide when other timed services increase in value. This way, we do not fight
alone against the insurance companies.
What does “15-minutes” mean?
It is very important to note that “15 minutes” is defined as
“personal one-on-one contact with the patient”. This means
that you are not only in the room with the patient, you are actively
performing a medically necessary activity that is a component of
acupuncture or electroacupuncture. The time that
the needles are retained is specifically excluded for reimbursement.
“Personal one-on-one contact with the patient” does not
mean hanging out with the patient and talking about their 5-element
preferences or their love life for that matter. We don’t get paid for
counseling under these codes. We don’t get paid for evaluation and
management of the patient under these codes except for the “usual preservice and postservice
work associated with the acupuncture services”. These codes are
for performing the procedures of acupuncture or electroacupuncture,
not for the initial history and exam or subsequent re-examination (more on
this later). You can think of this as the time your hands are doing some
component of the acupuncture service.
“Personal one-on-one contact with the patient” is
limited to; selecting, locating, marking and cleaning the points, washing
your hands, inserting and manipulating the needles, removing and properly
disposing the needles. The only exception to this is in the case of a
patient who must be continuously monitored. An example is a patient who is
nauseated and may vomit at any time. If you must be on hand to remove the
needles during the course of treatment, you may count that as face-to-face
time. Another example would be a patient who is getting distal acupuncture
for an inflammatory joint condition like sciatica (Yao
Tong Xue) or bursitis of the shoulder (St. 38),
and you are directing the patient to move while the needles are in place to
enhance and evaluate the effectiveness of the treatment. Or, perhaps you
are treating someone with low blood pressure and you must monitor the pulse
so that you can suddenly remove the needles to avoid fainting.
Evaluation and Management
You are also being paid to provide the “usual preservice
and postservice work associated with the
acupuncture services” that accompanies a repeat visit. The usual preservice work means that you greet the patient, take
an interval history, i.e., “How have you been since your last
visit?” and re-examine any positive findings from your initial exam
that you need to monitor to adjust your treatment (such as rechecking
tongue and pulse). At the end of the acupuncture or electroacupuncture,
you chart what you did and any instructions you gave to the patient. This
is the usual postservice work. In other words,
the level of effort that goes into performing the activities reflected in
SOAP notes is included in the work value of these codes. The preservice and postservice
times are expected to be about 3 minutes each.
When the patient has suffered a significant new trauma or change in symptoms,
or if 4-6 weeks have passed and you feel you need to perform a
re-examination to monitor the effectiveness of treatment, you may (if your
scope allows) perform a re-examination and bill an Evaluation and
Management code (i.e., Office visit). It is not appropriate to bill an
office visit with every acupuncture treatment.
How long should the treatment take?
Based on our survey, we think that the average treatment will be two units
of time, with one or three units being less common. No one is suggesting
that you use a stopwatch and note the times in your patient chart, but if
you are treating 20 patients a day, it would be ridiculous to claim that
they all received an hour of your undivided attention.
Please don’t change your clinical procedures to maximize your
reimbursement. Do what you normally do to achieve the best clinical result
and charge what you think your services are worth. Whatever you do,
document your care in your SOAP notes. In the case of a dispute, you must
have good SOAP notes to make your case that the time you spent was
medically necessary). Medical necessity is not documented simply by listing
a lot of points. You must show that the patient had subjective complaints
and objective findings that required treatment to the points you selected.
The CPT supplement has examples of treatments and how to code them. You can
buy that from the AMA.
Electroacupuncture and Acupuncture
Together
The CPT book doesn’t allow you to bill for a “mix and
match” of acupuncture and electroacupuncture
on the same visit. This is to prevent acupuncturists from charging for
inserting the needles (acupuncture) and then attaching electrodes to those
same needles (electroacupuncture). The insurance
industry does not want to pay twice for inserting the same needles. To
prevent that confusion, they simply set up the codes so that you will only
be reimbursed for billing either units of acupuncture or units of electroacupuncture, not both. So what do you bill if
you perform an initial 15 minutes of electroacupuncture
and a second 15 minutes of acupuncture without electrical stimulation? You
bill both as electroacupuncture. As inaccurate as
it appears, the relative unit committee decided that this is the best way
to handle the issue. The differential in reimbursement for the additional
period of acupuncture versus electroacupuncture
is small enough to be the lesser of two evils in the eyes of the relative
unit committee.
How much will I be paid?
This question cannot be answered. Insurance companies will determine what
they think is fair. In the case of HMO’s, the payment is by contract,
so the new codes may not have much effect. Some carriers may decide that
they will only pay for one increment of service in a day. Some may decide
not to pay you at all. If your patients are as unhappy as you are about
your reimbursement, they may advocate on your behalf. You may decide not to
accept insurance reimbursement from carriers who are too restrictive.
What is the relative unit value of our services?
The work value of a 15-minute acupuncture treatment is .60. This compares
with the work value of .21 for 15 minutes of ultrasound. This is an
excellent valuation for our services and represents a real triumph for the
profession. Because our codes are now timed, our work value will rise with
the tide as other professions fight to increase reimbursement for their
services.
Additional 15 minutes of acupuncture has a work value of .55. Electroacupuncture is valued at .65 and additional electroacupuncture is valued at .60. The additional time
codes do not include additional pre- and postservice
time. It is assumed that the additional periods of insertion do not require
additional pre- and postservice work.
How much should I charge?
Regardless of the new CPT codes or Relative Unit Values assigned to these
codes, you must decide what your services are worth. Neither the AMA nor
the insurance industry is setting your fees by assigning a work value to
your services. You set your fees based on your own business needs and what
the average cash-paying patient is willing to pay for your services. In
other words, it is the free market, not the insurance company that
determines the value of your services.
David Wells, D.C., L.Ac.
AAOM Insurance Committee