I want to talk to you a little bit about what’s been going on and I’m sure many of you have noticed on what’s called the medically unlikely edits or the limits to care. And I’m sure some of you have seen it.
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Hi everyone. This is Samuel Collins, the coding and billing expert for acupuncture and the American Acupuncture Council. But most importantly, the coding and billing expert for you. While I do have roles with the world health organization, United healthcare and Optum health. My ultimate goal is for the practitioners just as American Acupuncture Council is, and this is another addition to make sure that you’re getting things right, understanding what’s going on, promoting your practice. And I do the billing side I’m with the American Acupuncture Council Network, which means we’re part of the malpractice side that really helps you with the coding, the billing, the education and seminars we’re here today. I want to talk to you a little bit about what’s been going on and I’m sure many of you have noticed on what’s called the medically unlikely edits or the limits to care. And I’m sure some of you have seen it.
Hey, why are they denying? In fact, we’re running into some areas in New York where they’re paying only for one, which actually shouldn’t be what’s there others paying for two or three? Well, what is correct? What do we have to make sure we’re doing to make sure we are getting paid fully, but also making sure if they don’t pay us, what do we do about it? And where does it come from? So let’s go to the slide. So you can start to take a look at what’s happening. So in these slides, you’ll notice I have here. It says acupuncture, medically unlikely edits. MUE is what they term it. And what that deals with is the maximum number of services that can be done per day. And that’s not just for acupuncture acts. So that includes physical medicine and other services. And also want to hit a little bit on to medical necessity, cause that’s really kind of where this dovetails.
So if you take a look here and I know this is smallest, let me enlarge this a little bit for you. You’ll notice here. This is from empire blue, cross blue shield. And notice what they’re bringing to this doctorate says the review indicated your average utilization of acupuncture sessions of one hour or greater personal one-on-one contact with a patient is higher than expected. So that means you’re doing an hour more so than everyone else. They’re not saying necessarily it’s wrong, but because it’s above average, they’re trying to figure out why. So notice in the next paragraph I highlighted it says, we are aware of many factors that may impact the coding of your acupuncture services. Our goal is to assist providers. So they’re not necessarily trying to be punitive, but trying to figure out why are you doing more is for too much, not necessarily, if you talk to most acupuncturist and I’ve taught seminars now for 23 years.
And I would say the average acupuncture is probably does between two and three sets regularly. So four is not unheard of, but it’s not typical, but I would say the average is two or three. So when it goes to four on a very regular basis, there could be some issues. In fact, this is probably where the medically unlikely edits come from. Well, let’s talk about it from a medical necessity standpoint, if you’re going to do ortho, that’s why that’s part of what we have to determine. So I’m going to give you what medical necessity is determined by the company, American specialty health, which I’m sure a lot of you have a tendency to. There’s kind of a love, hate relationship with them. I don’t think the hate is so much from the protocols is just, I wish they paid more, but ultimately I do think they make a nice protocol for what they determine as medical necessity.
So always understand when you’re going to do four sets or more, the Y has got to be based on the diagnosis. The severity of the problem. Now the difficulty with diagnosis is often the diagnosis for acupuncture is simply just pain. So how does that really demonstrate severity unless you’re coding like a lumbar disc. It really doesn’t. So remember your chart notes are going to be an important factor. The past medical history of the history, including is it traumatic? Is it repetitive? Is it acute? In other words, severity, what’s also going to be part of that though, is comorbid factors. Things that can complicate the patient, things that are underlying patients, very overweight patient has a very poor diet. Patient is diabetic. While you may not be treating those things directly, could they affect how the patient responds? Meaning why did I do four sets, other things?
They look at our range of motion, palpatory findings, orthopedic testing, neurologic testing, but they also do look at the tongue and pulse notice all these say quantify. Cause we want to know, well, if it’s severe, these things would all be more severe as evidence and quantified do. Remember they will look at the functional limitation, how the patient is getting better or not better just stating the patient feels better is not going to be enough. We have to be, how is it better? What can they do now that they couldn’t do before? And there’s always going to be goals for it. So ultimately think of medical necessity as kind of looking at how you would see a patient overall in their improvement, not just paying level. And there’s something to think of. This is from a company called health partners and I liked the way they put together the factors that they look at for medical necessity, things they put in mind.
Notice the first thing, gender fatigue, lack of energy, notice mobility, agility, strength, sleep issues, not falling asleep. You know, not waking up feeling rested or just the decreased quality of life. Those are factors that if you quantify given issue of potential severity beyond just stating pain, now I bring this up because of course, if you’re going to do acupuncture, we know that there’s four codes and you know that the four codes are there to allow us to build additional services when necessary. Some patients may get one, two, three, or four, but what’s important to remember is that acupuncture requires two things for billing purposes, for billing purposes, you’ll notice the acupuncture code says one or more needles, which means you have to insert a needle. But then it also says initial 15 minutes and each subsequent code says the same thing. It says reinsertion, which really should be additional insertion and 15 minutes.
So the codes are really going to be based on inserting needles and spending time. So if you’re telling me that you’ve done four sets, that means you actually have to be in the room with the patient for the full fifth, 60 minutes or close to it and do four distinct insertions one in the first 15, second, 15 and so on, which is not something that you wouldn’t do, but you have to document it and let’s remember, and see here. It says how the 15 minute session is defined. Remember, as soon as you walk in the room with the patient, say, Hey, how are you feeling today? The time starts, all the things you do. That’s part of your acupuncture, including review of history. Hand-washing choosing points. All of that counts. What’s important is to document it because you’re doing multiple sets. The one issue we’ve run in through the American acupuncture council is offices.
Aren’t documenting that well. So that becomes a problem. Well, it’s also a problem just based on number. So let’s take a look here and I’ll show you. This is an example of a soap note for acupuncture that has documented three sets. And I want you to see here, and I don’t want you to really comment about necessity. Just show how it works. Notice each set is identified set one, two and three. Notice the points are identified in addition, the face-to-face time from and two, or it could be minutes and then retention. So clearly when you see here, you’re noticing there is clearly three sets because there’s three separate insertions as documented notice the face-to-face time equals hitting the eight minute rule, if you will. And then it shows the separate retention. Remember don’t count retention towards the total time. So if you’re doing multiple sets, we have to make sure that we’re documenting all those factors. Because if we’re doing two, three or four, it still has to be shown. Did we do it? Well, this brings me to this kind of medically unlikely edits or what CPT does is they do edits for all types of codes. And there’s two types of edits that are common.
The first one is called the correct coding initiative at it. Yeah,
That is one that the correct coding initiative edit is one that there we go is used for coding, such for chiropractors, like a chiropractor. When they Do manipulation, there are codes that are part of manipulation That have to be separately coded. So by example, they Have to not code nine 71, four zero With manipulation. This I apologize. My phone is,
But you have someone who keeps trying to call through. So I apologize That these coding initiatives, goodness, here we go. And my apologies for this, I Cannot seem to get someone to understand what a message says. I’m not available. That I’m not Nonetheless, they kept trying let’s do this.
Okay. My falsies bear with me, correct coding initiatives. Just tell me what codes can and cannot be billed together. Okay? So for chiropractors, that’s common for record Puncture. It’s not, but we’re acupuncture does help.
Some common issues. Common issues for acupuncturists are under something called the Medically unlikely edits.
Medically unlikely deal with codes that can not be coded for an excess amount of units. Now you may think, what does that mean? This is where it comes in. You’ve noticed where they’re saying acupuncture can only be billed for say three sets or two sets depending on who you’re dealing with. That’s what they’re referring to. So what are you Louise there for any CPT code that the maximum amount of services that will be provided under one visit or a date of service, this applies to all types of codes. So by example, to show you where it’s also applies, it’s not just for acupuncture. Things like modalities have one, some have four. If it’s an attempt to Allie, when it’s timed such as notice the here it’s just the unattended services or one notice the codes for electric STEM allow for, but then ultrasound is only two. And again, that’s just based on these edits that say that’s the maximum per visit we’ll procedures. Get a little bit different. Notice for exercise nine, seven one one zero. It is six
For neuromuscular education. It is, it is for
Because it’s a little different service than exercise. So they’re limiting to four notice massage only four. Now you may say who comes up with these it’s part of the coding committees edits that do such. So make sure that you’re using the correct codes and amount of units. Now I doubt many of you go well above that notice manual therapy says six. So these are what they’re going to indicate as the amount that you can do maximum per day. So if you did more than six, they’re going to say no. Well, where does our services fit? You can see here therapeutic activities, by the way, I chose these codes here on the right side specifically because that’s the limits for those codes. But also those are the codes. If you’re billing VA patients, those are the services that the VA will automatically authorize for acupuncture providers.
But here’s what we’re running into. As I mentioned, the VA, take a look here. Here’s what’s called the standard episode of care SEOC and you’ll notice it says for acupuncture 12 visits, but notice it says a maximum of one additional unit of acupuncture with, or without electric STEM when reinsertion of needles. So under this one, and this is an Optum health, when they’re saying, Hey, you can only do two. And I’m sure many of you have run into that. Whereas before you could do four or five, it’s just saying they’re allowing only two. So that’s OptumHealth now again, that goes against what the normal edit says, because notice this one from tri West and you’ll see, this is really just from December. I know you can’t see the date, but you’ll notice here. It says the maximum unit
Acupuncture. And you’ll notice the map
Maximum units for acupuncture indicate nine, seven, eight one zero. The first set is one unit, but then the additional sets notice are two. So notice they’re indicating under this correct coding under the many medically unlikely edits. The limit is three, meaning one initial set and up to two additional sets. Now to give you a little history of that, that hasn’t always been the case. I want you to see here. This comes directly from United healthcare, and this is dated notice 2018 through 19. And it was different. It says the medically unlikely edits indicated that you can do one initial set, but then three additional sets of manual. And then electoral was one and two only. So three total. So at that time it was four, but let’s fast forward to this year. You’ll notice again, this is the health care notice from 2020. And now it’s indicating that according to this edit notice here, it says the policy enforces the code description for acupuncture services, which are to be reported based on 15 minute time increments, personal face-to-face time.
And it’s indicating in accordance here nine, seven, eight one zero is one. By the way, one makes sense. You can only have one initial set, but then notice instead of it being three, it is now two. So that’s also two here. So what is the new rule for medically unlikely edits for acupuncture is three. Now what if you say Sam, I need to do more now. Medically unlikely doesn’t mean an absolute, could you defend doing more and request more? Sure, but now you’d have to show the medical necessity of what did my fourth set do that wasn’t completed within the first three sets? I think there’s some things that can be disputed there, particularly if you’re doing front and backside sets multiple diagnosis, but again, you’d have to kind of come up with what is the fourth set doing that the others aren’t simple answer.
If you build three, you should not have much problem, but we’re seeing issues here. This is a United healthcare, and you’ll notice on this visit, they’re paying the one initial set they’re allowing it, but then notice this one they’ve taken out. It used this code in three, six, two. So what does [inaudible] mean? Well, let’s look at this full EOB notice in three, six, two says the number of days or units exceeds our acceptable maximum. So let’s take a look at what there are allowing notice on this one, visit on 10 27, they’re allowing the initial set, they’re paying the full amount or allowing it, but then on the additional sets they allow the nine seven eight one one four one and nine, seven eight, um, one, one again, but then not allowing the third set or the third or four set, which would be the nine, seven eight one three.
Now, even this one here, what I’m trying to point out is that they’re beginning to say, Hey, we’re not going to pay more than three if you bill such. So you want to make sure that if you’re billing more than three chances are with some payers. And I will tell you anthems Cigna, Aetna, as well as United have begun to really follow this as well as the VA. So what do we need to do to make sure we’re getting paid properly is to make sure we’re number one, sticking within the three. And if we’re going to go more than three, we’re going to have to send explanation, but here’s one of the problems we’ve run into. There are some plans, even like this one that they’re not paying that third. So when that happens, what’s going on. Here’s another one and this is an empire or excuse me, a Cigna, excuse me.
And I’m just going to blow this up so you can see here. It indicates the number of units built for this service exceeds the limit for the day. Now, if you look at this bill though, they’re allowing the first set and the second set, but not allowing the third. So then wait a minute. Why are they not allowing that amount or excuse me, they are allowing that amount. I want to share this one is doing three. So there’s one initial one, follow one follow. But then the fourth is saying no. And that comes from those edits. If you were billing more than three, you’re very likely to be denied for the fourth. Some payers may allow, but most are going to follow these edits. But what if you’re running into an issue with it where you’ve billed only three and they’ve denied it, then I’m going to push back.
Here’s a letter. And you know, you’re welcome to kind of see how it does. It just brings up the points of I’ve recently received a claim for payment that was denied due to the medically unlikely edits. And you’re going to bring up the medically unlikely edits indicate that there should be three. So if they’re only paying for two, this is the response. You have to say, the medically unlikely edits indicate three, unless you have a contract otherwise. And I’ve seen a lot of plans doing this. And I think what’s occurred is a lot of them have misinterpreted the edits and somehow are allowing to, so you want to make a little bit of a pushback. In addition, for those of you who are billing Optum, when you’re billing, Optum, meaning VA, and they’re only allowing two, here’s my concern. How is the Western part of the country try West allowing three and the Eastern part of the country only allowing two yet.
It’s the same, the same benefit. And of course it’s because Optum has misinterpreted it and there should be three. So this is a little bit of the pushback. Is this something I’m very excited about? No, I don’t like to see any limitations, but we have to know what we’re working with now. The good news is three sets is pretty typical that most aren’t going even that high. In fact, I’ve taught seminars now for 20 years. And I would say on average, when I asked the room, how many people are doing four sets, it’s a very minor percentage. But when I ask who’s doing two or three, it’s most so again, if you’re sticking within two or three, this may not make much of an effect, but if you’re doing four, a Canon may want to rethink of what’s going on. Now you can see, this is what I’m here to do is help you understand it, help you fight back with it.
And I’m going to say, give me a chance to help you do that. The American Acupuncture Council is your resource for these courses, but also I’m a resource. Allow me to be part of your office, take your phone out, take your camera and just put it over that code. And what that’s going to do is give you an opportunity to hire me for your office, but we’re going to give you the first 30 days for no charge. Give me a trial. Let me help you with a claim. Let me help you show what’s going on. Realize these rules and codes. We have fight back letters and all types of things that we can do that I can aid you and making sure you’re being properly paid and not having something where your claims are constantly being denied. Think of how many times you’ve had denials for ENM codes or other services that were not correct.
What do you do about it? I’m going to give you the rules and the laws, not opinions to fix it. The American Acupuncture Council is your resource. Allow me to be part of your office. You can join for as little as $25 a month, or you can do it with seminars. So I’m going to say, take a look at the services we offer I’ll guarantee you’ll get help. In addition, take a look on our site when get there. I’ve got videos and things of other things that we have done and looking at our news section for updates, we are here to help and I want to make sure today you understand what do I deal with and how do I deal with medically unlikely edits? What do they mean if I can do three great, but what if they’re cutting me less than three? But what if I do four?
How do I fight back for that? So that’s what we’re here to do is to help you for that. So I’m going to wish you well and say, stay tuned next week. The, um, host will be Jeffrey Grossman, and I’ll see you next time. I hope I become part of your office. Take a look at our site, take a look at the services we offer. We’re here to make your office successful. Don’t guess let’s make sure you’re getting paid. We do much more than just simply tell you a code. We make sure you’re doing it right. Thank you everyone.
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