Hi, everyone. This is Samuel Collins, your coding and billing expert for acupuncture at the American Acupuncture Council, our seminars, our networks, and all that. And I welcome you to another program of To The Point. In fact, let’s do that. Let’s get to the point. My goal, as always, is to make sure to give you information that’s up-to-date, current, and keep your office practice going strongly.
So what’s going on? Well, of course, what’s going on right now, of course, is Medicare. And of course, Medicare and acupuncture has had a lot of confusion, and I want to clear up that confusion and kind of give you some insight as to where you can fit what we can do and what we can do for the future. So where are we going with Medicare and acupuncture? Well, let’s take a look, go to the slides.
So we start off with just simply Medicare and acupuncture. Always know that my email is here for you as well. But let’s talk about what has occurred for Medicare. July 15th of last year, the Trump administration proposed a plan to cover acupuncture for Medicare patients with chronic low back pain, framing it as a step that could more safely treat pain without supplying patients with opioids. And of course, this is kind of what happened because of the VA. Opioids have become a big problem. They’re looking for something else that can be helpful. So credit to that, we’re working towards a proposal.
So this is what happened in July. The Trump administration proposed this for patients with chronic low back pain, so they could safely treat without using opioids. Okay. So what does safely treat mean? Well, acupuncture. The proposal released, though, would only be for patients enrolled in clinical trials. So this is what initially happened, just clinical trials and under the National Institute of Health. In its statements, CMS acknowledged the evidence base for acupuncture has grown in recent years. However, questions remain.
So what they did was they said “We’re going to open up a dialogue,” and they allowed everyone to send in information to see whether or not it would be helpful. And the idea first, and as I was told by many people in NIH, it was solely going to be just a study. They were going to put a few people in a clinical trial. Well, after all this information, lo and behold, I put fireworks here, January 21st, what I thought wasn’t going to happen happened.
But I’ll give a note. Marilyn Allen, who many of you may be aware of, and I had spoken with a few people at NIH that said something the week before. They said, “When you get acupuncture.” They didn’t say, “If,” they said, “When.” And we thought that was a little puzzling because we thought, “Okay, it’s going to be a study. We have to see where it’s going to go.”
Well, what happened on January 21st is they made this announcement. “The Centers for Medicare and Medicaid services finalized a decision to cover acupuncture for Medicare patients with chronic low back pain. Before this final National Coverage reconsideration, acupuncture was nationally non-covered by Medicare. CMS conducted evidence reviews and examined the coverage policies of private payers to inform today’s decisions.” So what they did was they got enough information from private payers and others to just decide, “We’re going to cover it.” They didn’t need to do a study. They’re just flat out going to cover it for chronic low back pain.
So what does this mean for us? Well, the decision regarding coverage takes into account the assessment benefits and the harms of opioids. It says, “While a small number of adults age 65 or older have been enrolled in published acupuncture studies, patients with chronic low back pain in these studies showed improvements in function and pain. The evidence reviewed for this decision supports clinical strategies that include nonpharmacologic therapies for chronic low back pain.” While there is variations in indications, the bottom line is they said, “No, we’re going to cover chronic low back pain for acupuncture.”
This decision was published in a memo, if you will, and it’s the CAG-00452N, so if you want to look it up. But here’s it in a nutshell, and what it says is this. “The Centers for Medicaid & Medicare Services will cover acupuncture for chronic low back pain under section 1862(a)(1)(A),” which is the Social Security Act, that will cover up to 12 visits in 90 days covered for Medicare beneficiaries so long as the following circumstances are met.
For the purpose that means chronic low back pain is defined by Medicare means it’s lasting longer than 12 weeks, so you’ve got to make sure in the chart notes and history, this patient didn’t just wake up with back pain, but it’s some back pain they’ve had off and on for 12 weeks or greater.
It’s nonspecific that it has no identifiable systemic cause, not associated with metastatic inflammatory infections or other diseases of course, not associated with surgery, and not associated with pregnancy. Now, I will say this, I doubt we’re going to have very many 65 year olds with pregnancy, but that of course is based on some of the other guidelines.
However, beyond the 12 visits they will authorize within in the first 90, an additional eight sessions will be covered for those patients demonstrating improvement, but it says no more than 20 acupuncture treatments may be administered annual. Bear in mind that these 12 visits or initial 12 visits are within 90 days. If you use those up, you certainly could get approved for more. The exciting part here is that the acceptance and how quickly it was to deal with acupuncture and low back pain.
Now, some of you are aware, I have a chiropractic background, but technically if you look at some of the studies, by a small percentage, acupuncture has shown potentially greater outcomes for back pain than does chiropractic adjustments alone. That being said, it also indicates treatment must be discontinued if patient is not improving or regressing. Well, here’s the good news. When someone comes to an acupuncturist with back pain, generally what happens within one to three visits, they’re already showing some levels of improvement. So I don’t think it’s going to be very difficult, though you want to focus on two things: pain reduction and increase in function.
Now, in general, this is the guideline under section 30.3 for acupuncture in Medicare that never covered it. And it says, “Acupuncture,” of course, “is a selection and manipulation of specific acupuncture points.” And it says effective for dates of service January 21st. So actually, when did this begin? January 21st.
Now, the good news is yes, but there are some restrictions, and this is what most people assume that maybe an acupuncturist could bill directly. Well, let’s talk about what is the billing provider versus the performing provider? Because under this provision, this still does not give any indication that an acupuncturist can join Medicare. That’s something that’s going to require an act of Congress. But the billing provider must still be a provider that’s enrolled in Medicare. So that’s going to be a physician as defined by Medicare, which means essentially an MD. So a physician as [inaudible 00:07:08] by 1861 is going to be your medical doctors within their state requirements.
However, it’s also going to allow physician assistants, nurse practitioners, clinical nurse specialists, and other auxiliary personnel to furnish acupuncture if they meet the applicable state requirements. So remember, acupuncturists are going to fit under this auxiliary personnel, which means yes, you can work on Medicare, but under the supervision or direction of the MD as so long as the person, and this is the nurse practitioner, has a master’s or doctoral level or degree in acupuncture or Oriental Medicine by an accredited school or a current, full, and active, unrestricted license to practice in a state or a territory of the United States.
In other words, they must be a licensed acupuncturist, if not an MD. An MD can do acupuncture should they choose. Obviously, most won’t. They’re going to refer to someone. So that referral could go to a nurse practitioner, but of course, the nurse practitioner can only do it if they also are licensed for acupuncture. Therefore, this is the opportunity for acupuncturists to work within an MD setting where the MD prescribes, the acupuncturist performs, and it’s billed directly to Medicare.
Now, auxiliary persons performing it must be under, and I’ve underlined it, “the appropriate level of supervision.” Now, what’s important to see here is this distinction. The term “appropriate level” is a little bit different from what others will often state. Generally, what it’ll say is “direct supervision,” and of course, it needs supervision, but “appropriate level” doesn’t mean that you need as much intervention by the doctor, if you will, the medical doctor in order to provide the service. That’s going to still be more up to the practitioner of acupuncture.
But this can be the supervision, bear in mind, of a physician assistant, a nurse practitioner, or a clinical nurse specialist. So this certainly could be an opportunity where you may have a nurse practitioner that practices with an MD overseeing them, but then has a separate business where you work with them, either they come to your office or you go to theirs, and can furnish these services.
The bottom line is the type of supervision required was changed at the request of the acupuncture profession from direct to appropriate level. This accommodation adds a tremendous amount of latitude for collaborative agreements between LAcs and MD providers or even DOs, nurse practitioners and all. While nurse practitioners and clinical nurse specialists and physicians assistant may not practice acupuncture, their supervisory availability also vastly expands the potential for collaborative agreements, which means it doesn’t necessarily need to be an MD. It could be under a nurse practitioner, physician assistant, and so forth. So it means you don’t necessarily have to work directly for an MD but might be working in a clinic setting where there’s a nurse practitioner or other type of provider that can be registered with Medicare.
The difference here, though, is it’s obviously, an acupuncturist cannot bill directly, so you’re going to hear this term a lot called “incident to.” So in order to bill acupuncture, an acupuncturist must be working incident to this provider. So what does “incident to” mean? It means the service must take place in a noninstitutional setting, which in simple terms means not in a hospital. Number two, it must be a Medicare-credentialed physician that must initiate the patient’s care. So we have to make sure the supervising personnel, if you will, examines, determines, “Yes, I believe they can be helped by acupuncture.”
Subsequent to the initial encounter to which the physician can arrive at the diagnosis, this nonphysician practitioner, meaning auxiliary personnel, may provide the follow-up care. So then the acupuncturer does their work, and then once every thirty days or approximately thereof, this supervising person will just check to see how the patient’s improving or not improving.
Then the next step is the care must occur with direct supervision or the appropriate level. Per the Benefit Policy of Medicare, what does that actually mean? Does that mean you could have someone just give you a referral for acupuncture and you do it in your office? The answer to that is no. Direct supervision in the office setting does not mean the physician must be present in the same room with his or her aide or auxiliary personnel. However, the practitioner must be present in the office suite or immediately available to provide assistance and direction throughout the time the aide is performing the services.
So now this is going to get a little bit different here because notice it says, “Immediately available.” For instance, under auxiliary personnel such as a nurse practitioner, it doesn’t necessarily mean in the office. Under this guise, I’m going to state at this point, you want to make sure you’re working with direct supervision, they’re in the facility, and I think you’re going to be at your safest bet.
However, Medicare will begin paying for acupuncture. And I have not any practitioners yet, but I certainly have a few that are already working with the MD setting, so I’m waiting to see the bills come in.
Ultimately, this. The physician or the supervisor must be actively participating and must be working in the management in the course of care. They can’t just prescribe and not be involved at all. Both the credentialed and physician may qualify for this incident to so long as you’re employed by the group. So remember, you’re going to be working as an employee in some way to this person. You’re not going to be working as an independent contractor. In order to be supervised, you have to work as an employee. Independent contractor means it’s billed under your own name; therefore, that’s not going to fit here.
Now, is this as good as everyone was hoping or wanting? I would say not. However, bear in mind this. This was only supposed to be a study, and it started in July, but by January they decided, “Nope, we don’t need the study. We’re just going to cover it.” So I see this as neither a slight to the profession nor an error in any way. Provider types outside of Medicare are by the CMS definition of auxiliary personnel, must be supervised by Medicare providers. But remember, it doesn’t necessarily have to be an MD. This is the maximum freedom that can be granted until the Social Security Act is amended to include acupuncturists.
Now, here is the big problem for us. We need to make sure that acupuncturists, by an act of Congress, can become providers under Medicare. Once that happens, there will be direct billing, and I think that certainly will be the area that we’re looking towards that’s going to be more cost effective. The bigger issue for us, though, the power does not rest with CMS as much, it rests with our profession and dealing with Congress, meaning we need to make sure as a profession we have some type of national certification where we make sure that they can be trusted, that these services are under a guideline that’s standardized on a national level. Not to say that you can’t do things differently, but that we’re going to have to have some national standards, if you will.
The excellent news here is that they’re going to cover acupuncture. Now, some people are going to wonder, “Well, what do they mean by cover?” Well, they’re going to cover the acupuncture codes themselves, meaning they’re going to cover 97810 to 97814. And you may question, what would be the prices of these codes? Well, to give you an idea, the Medicare uses a conversion factor for their codes. The conversion factor is roughly between 37 to $40 depending on the region you’re in, and they base it on the relative value unit. The relative value unit for manual acupuncture is about 1.03, and for electroacupuncture is about 1.15, which means you can assume the first set is going to be paid somewhere in the $40-plus range, the additional sets likely in the $30 range. For many of you, that generally is going to mean what you’re seeing for VA in many instances.
This is a real great step forward, but I do want to warn that it is not for direct billing. We still cannot join Medicare. However, what about working collaboratively? What about talking to some MDs in your area where possibly you work in their office a few hours a week or even just a few hours a month, if you will, to start treating some of these patients to see how they’re doing? Remember, Medicare is a big insurer. Everyone over 65. And how many people that have Medicare probably have a little back pain? It’s a tremendous number. And what they’re trying to do is to give persons an alternative.
Here’s what I will say. Acupuncture works well. Once we start getting more and more of these services provided, you’re going to see where Medicare is going to come on board, allow acupuncturists to join and bill directly. But as of now, what about working collaboratively? So is Medicare perfect for us? No. But think of this step. Who could have imagined even a few years ago that this would have occurred?
I want to thank you for spending some time with me. Please take a note, if you go to our website, the American Acupuncture Council Network, and go to our news section, we have this information and much more on upcoming changes and things happening with coding. I suggest go there, sign up for our email service. What we provide are lots of news items.
I’m going to give you a couple of quick items that are occurring. UnitedHealthcare is requiring modifier GP on all physical medicine codes regardless of the profession. As of note for any practitioner in the New York area, New York Empire is also now beginning this GP modifier. And as I’m sure you’re aware, the VA is doing so as well. In addition, of course, things are changing for the VA. Of course, on the East Coast, they’re now using a company called OptumHealth. The West Coast continues with TriWest.
As always, we want to be the most effective place for your information. Take a look at all of our sites. And I welcome you to always come in and say hi to me. Also, coming up next week will be Moshe Heller. And I wish you all the best, and continue your practices strong. We want to be with you and To The Point. This is Sam Collins.
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