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Limits to Acupuncture Sets Per Visit



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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hi everyone. This is Sam Collins, your coding and billing expert for acupuncture and the American Acupuncture Council. With another episode to always make sure that you’re on point and making sure your practice is continuing to thrive and to grow our role with the American Acupuncture Council and my service, the network is to always help.

Be the best it can be in implementing the care for your patients and ultimately being paid. One of the things that comes up and I’ve had this question quite a bit from members is there some sort of limit to the amount of acupuncture I may provide someone and that’s a question, certainly some people think do what can I only do two, can I do four?

What is my protocol? Is there some sort of. That I must follow and in a way, yes, but in a way, no. So let’s talk about that. Let’s go to the slides. Let’s talk about what’s going do the type of acupuncture you’re gonna do and what are the limits. So from here, you can see just my basic information, there’s our website, my email address for those that need some extra help, but let’s talk about the care of.

Let’s talk about what is reasonable or what is necessary and what I’d say that always comes back to as a medical necessity. So I’d say the limits to acupuncture more than anything is going to be, what does the patient need? What does it medically necessary? Let’s define that here’s a statement from Cigna Insurance specifically on their acupuncture policy, which by the way, just recently updated.

And it says medical necessity decisions must be based upon patient presentation, including diagnosis severity. And documented clinical findings. So in other words, the more severe the case, obviously the more severe the diagnosis, the more care they might likely need. So you’ll see here, they’re not really putting a limit per se.

What they also indicate is that an individualized treatment, meaning frequency, duration, and so forth is appropriately correlated with the clinical findings. So again, it goes back to severity. So when someone says to me, Sam, is it okay? I do four sets. I’m going to say it can be. But it’s gotta be, is that’s what’s needed it.

I would be careful of a being something that’s based on my style that everyone gets four sets, no matter what. It should be based on what the patient needs. Let’s give one more. Let’s take a look at what Aetna says, and this is Aetna’s clinical policy bulletin, which has also just been republished again, but for 2022, and it says this acupuncture services are considered medically necessary.

Only if there is a reasonable expectation that acupuncture will achieve measurable improvement in the patient’s condition and is reasonable for a predictable period of time. In other words, we’re showing we’re making the patient better. So I’m trying to highlight here is that. They don’t really give a definitive that you can or cannot do whatever is necessary.

In other words, could some patients get better with two, maybe three or even four? Here’s something that came out and we’ve had a lot of offices gotten letters like this. Here’s one from the company empire, which is out of New York, but this is an Anthem company. And we’ve seen this across the U S of course I teach seminars all over and you’ll see here at.

The review indicated your average utilization of acupuncture sessions of what hour are greater or what are greater for personal one-on-one time is greater than what we consider the average of providers. So right there, they’re saying, oh, you’re doing an hour. That’s greater than the others. Now you’ll notice it.

Doesn’t say you can’t do it. It just says, because you’re doing more. They’re trying to say why they’re questioning it, but notice what it says here. We are aware of many factors that may impact the coding of your acupuncture services. So they’re indicating if it is with, for I know someone who treats post-surgical, that is her absolute specialty.

That’s all she does is referrals. Post-surgical patients. She goes, Sam, I generally sometimes do two hours. She’s doing six, seven sets on these patients. But when you think. These are post-surgical patients, lots of severe pain. So would that be reasonable? If they were questioning this, you’re going to just have to be able to respond.

It’s reasonable based upon the severity and need. So is there an absolute artificial limit while in some instances there is. You’ve probably seen something, what they call the medically unlikely edits MUE it’s often termed and you’ll see here. This is the United healthcare is promotion of it. I won’t say promotion, but their indication of it.

This is set up on a federal level and it says this, it says in accordance with the code descriptions and or the centers of Medicaid, Medicare services, meaning medical. Guidelines that CMS national coding initiative, it says the following are, the service limits are as follows. And you’ll notice the initial set is one.

Of course, how many more sets can you have than the first set? The first set is always one, but notice the additional sets all indicate two. So in other words, the amount of sets per this guideline says there’s going to be three pre-visit. I will tell you a lot of carriers have adopted this. I’ve seen this, not just with, I seen it with Cigna plans as well, where they’re pushing these three set part based on this medically unlikely edit.

Now you might look at this and think, wow. Are they picking on our profession? Not really because every profession, chiropractors, physical therapists have limits just like this. And you’ll notice here, I’ve just given a quick list of common codes. Obviously I put acupuncture, chiropractic notice for acupuncture.

The one. The initial two additional chiropractics, only one. And then you’ll notice certain therapies. Like by example, if we moved down to massage, you’ll notice they allow up to four, meaning once you’ve over one hour, they’re going to say no, and these are kind of artificial limits, but they’re just saying they don’t feel that often.

It would be reasonable to do much more than that. So now the issue becomes, if I’m billing insurance, am I limited to this? In a way, it’s what the insurance may cover. They may only cover that many. Can you do more? So let’s say you’re an out of network provider and the patient has a policy where it only pays for three.

Could you still do four and be paid for four? You could, but not by the insurance company. The insurance company is going to pay three who would pay the. The patient. So you have to be willing to make sure informed the patient. Your plan allows a maximum of three. However, for your case, I believe we need four and here’s the additional charge.

That’s if you’re out of network, here’s the downside. What if you belong to an insurance? So let’s say you belong to United as a provider. You will be limited to three. And if you do a fourth, absolutely. You can do a four. But you will not be paid for it and you can not collect from the patient. Cause remember when you join an insurance, you’re abiding by their rules, which means if they allow three, that’s the maximum that we can do for reimbursement.

If you do more go right ahead. There’s no additional money. So you have to make sure beyond these plans. When you join an insurance, you now will become beholden to these rules. If you don’t belong to the plan, you can tell the patient, this is what your insurance covers. This is what we need. And so therefore you do, what’s medically necessary.

Obviously people want to use insurance and we want to give them the best access, but maybe it doesn’t always cover everything. As we’ve all witnessed. How many of you have been to a doctor and you’ve had to pay substantial money out of pocket or things weren’t covered because your plan didn’t cover.

What do you do? You pay out? Here’s one. This is tri west. Now try west. Remember is on the west coast. Basically Texas and west of Texas that handles the VA. And you’ll notice they follow the same thing, one initial and two followup. So you’re seeing this also for the VA side federal plans obviously, and realize that’s also for Optum, which is part of United.

So to answer directly for some plans, there is a limit of. That’s payable. That doesn’t mean you can’t do more. It just means your limit for payment is three. Which means if you’re in network, you’re stuck with three, but if you’re out of network, can you build a patient for additional you’ll notice the anthems didn’t fall that I’m going to always say, treat what you need to do for your patient.

Treat the patient. Not insurance. Remember insurance is nothing more than an eight and never feel fully trapped into it. You’re going to let someone know here’s what your coverage covers. Here’s what we need to do. Here’s the difference provide what is necessary for your patients. So if you need to do four sets, do four, but if you’re in United health care, you will be limited to three.

So be conscientious of following through and understanding different plans and understand what your rights. In the sense when you’re in network or out of network, remember when you’re out of network, it’s up to you to charge what you feel is reasonable and the patients can choose or not choose to get it.

But bottom line is you are not limited unless you belong to something. When you belong to something like the VA, oh, they can say three are United. And so I will say the medically unlikely edits is there. If you go to a massage there. And they want to do two hours, but the plan only pays for who’s going to pay for the additional hour.

We, as the patient or the patient would, so same idea here. What I want you to take away from this is do what’s medically necessary, do what your patient needs, but just be careful understanding when you belong to a plan, there can be limits. And that limit is three to give you a little history of it.

Pre 2019, it was actually for manual. And three for electro and post 2019, they removed it and went down to three. Now the good news to that is I would suggest that many patients, I know me and myself as a patient, I’ve often not gotten much more than a 30 minute, maybe 45 minute. I’ve never had an hour treatment and I’m not saying anything wrong, but I think most patients can respond.

So we want to treat what’s adequate and be careful if you’re doing an hour. And here would be my question to you. Does the patient really need the hour? Are you just doing extra because you’re not busy enough and I’d sometimes be careful of that. Be careful of having a patient that you overdue, just because you feel like you want to throw everything at it.

Be. Be mindful, be helpful. What’s your patients they’re looking for is a response to care whether it’s going to take 30 minutes or an hour. So don’t put yourself in the realm of limiting, but also bear in mind. What is my cost benefit ratio? And remember, benefits are continuing to increase. Take a look.

And the benefit of 2022, it says Aetna will add acupuncture as a standard benefit in new and renewing commercial health plans in 2022. So everyone who has a commercial Aetna plan will be covered. Now, this doesn’t mean some of the federal ones, but all the commercial ones will cover, which means greater access.

Now will Aetna limits you to three sets? I’ve not seen them. I will say Optum United. But not Anthem and Aetna bear in mind, again, medical necessity. What comes down to, we want patients, we want access, give them the best help and understand do what is medically necessary. We’re always here to help remember the American Acupuncture Council, specifically the Network, not the insurance side.

The network is here to help you. I can become part of your own. Where you can call me, email me, fax me. We even do monthly zoom meetings. Take a look at our site, take a look. It’s very reasonable and as well as always gives you access, have an expert on your staff. Always reach out to us, go to our site. And I’m going to say to all of you.

Thank you. Continue success. Peace. Be with you, my friends catch you next time. Oh, and don’t forget, they’re going to bring it up on the screen. There is another show this Friday, and it’s going to be Michelle Gellis please tune in. We’re always here to help take care of everyone. Seeing that.