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Aetna’s Mandatory Acupuncture Benefits



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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.

Hey, greetings all, it’s Sam Collins. You’re coding and billing expert for acupuncture in the American Acupuncture Council. Most importantly, for the profession and for you. Let’s always work on getting your office. to be the most profitable in business that we can. I’m the expert when it comes to coding and billing, which means also though, for payment and how do I make my office survive?

And it’s not just insurance. It could be cash, and we work a little bit on all those. But today, let’s focus on what’s going on with insurance coverage, particularly with the company Aetna. It’s at some nice changes, but it’s important to know though they’re increasing or having mandatory. , what do they actually cover?

One thing that you have to be careful of is understanding what codes they will pay or will not pay to make sure and assure that your claims get paid. Frankly, make sure the patient gets the best benefit and you’re paid for your services. So let’s go to the slides. Let’s talk about this acupuncture under Aetna.

And its mandatory coverage, but what does it cover is what I’ll say. Well, let’s talk about where Acupuncture’s really move or has moved. There’s a much broader access to acupuncture. Why does that happen? Frankly, it’s consumers who want it realize that the additional coverage that people are getting is because the want of customers out there who want it.

In fact, you’ve probably seen some of the commercials for the Medicare Advantage plans that literally use acupuncture as a way of marketing, so consumers are looking for it. Obviously, insurers. Why are insurers looking at it? Well, they’re realizing it helps, saves. But it also is sort of mandated based on opioids and some other issues.

So we’re seeing access there. Obviously the Affordable Care Act has helped because it’s made mandatory in five states, but now there’s been two that have been added. So for those of you who are in Oregon and Colorado, you now have also mandatory acupuncture benefits on all plans under the Affordable Care Act.

So that’s a good thing. That’s in addition to the other five states. Of course, the VA has created. . That’s nice. Medicare has not quite where we want it, but we’re getting there. And of course the big thing is the opioids have probably created most of that to be there. Why? Well, let’s take a look. 37 State Attorney Generals of National Governance Association have now endorsed and say they want more acupuncture.

They need it to be included. Why? There’s a few issues. For the most part, it’s just a money saver. If you go to an acupuncturist, that’s $600 compared to a primary doctor, which is 17. In addition, when a person contacts an acupuncturist, 30% of the cases compared to 70%, they’ve done the work. When people go to an acupuncturist first, it will save Medicare 230 million in its medical budget per year.

That is a big change and a big money maker. So insurance companies are starting to pay attention. The American College of Physicians for back treatment guidelines now indicate acupuncture. Even the FDA now says, Hey, for non-pharmacologic people should be doing acupuncture. There’s a bill going through Congress now in California to specifically make sure that there’s always access to acupuncture for people that are gonna need opioid.

To know they have that access, that there is something beyond taking an opioid. Well, even the CDC has gotten on board saying, Hey, when prescribing opioids, clinicians have 12 recommendations for acute subacute acupuncture. Non-pharmacological has gotta be part of that. They highlight the benefits, the effectiveness of it, and health insurance should continue to improve that because creating more access saves everyone, not including the people who take opioids and can overdose The CDC guidelines now, all specifically all.

about acupuncture. So I think what we’re seeing with a company like Aetna is what they’re doing is creating where people have more access. So you’ll see here in 2022, Aetna is added standard acupuncture benefits and new and renewing commercial health plans. So anyone who has Aetna through their job commercial plan, is going to have now acupuncture benefits.

That’s really cool. Aetna’s always had acupuncture benefits for some plants, but not all. And I’m sure some of you’ve run into that. You’re thinking, oh, it’s covered. Then it comes back, oh, it’s not covered cuz we only cover it for, you know, uh, this, uh, surgeries if you will for, uh, anesthesia, that type of thing.

Now it’s gonna have a standard coverage, which means all plans have it. So here’s the good news. If someone has. Do they have acupuncture? They do. In fact, it’s governed under their acupuncture and dry needling guidelines, which is their clinical policy bulletin, and it says, now standard NAPLANs STEM coverage of acupuncture for medically necessary indications.

So now here becomes the difference because it’s covered. Does that mean they cover everything an acupuncturist could diagnose or. No it doesn’t. It’s still limited, but that still means there’s a lot of access here. So they’re gonna limit it to the coverage things that they do. Now, this is what I wanna be clear on.

You wanna know what codes they will or will not pay for. This is what we do with our seminars. This is what we do for my network members to make sure you’re updated. So you’ll notice here the next review was just this year. They haven’t published it yet. We probably won’t get any updates to this probably until June or July.

I’m not sure it’s gonna update very much, but it’s going to follow along these lines. And it’s very specific about what it covers and you’ll notice it gives about 10 things that it will cover. It covers when medically necessary neck pain. It covers headache. Now those are relatively new. It used to not cover those, but it does say chronic.

So kind of that it’s been there for 12. Now, I think for many patients, chronic conditions like this aren’t hard to muster simply because it’s not always an acute issue, but a patient will go, I’ve had these headaches on and off for months. Well notice also it covers low back pain. Well notice it doesn’t say chronic low back pain, which now means it can be acute as well.

It also includes nausea of pregnancy, osteoarthritis of the knee or hip. So knee or. Does it cover arthritis? Are there is No, they’re saying near hip. So near hip pain. It also covers nausea from, um, chemotherapy. So, so-called chemotherapy-induced nausea, dental pain, which is kind of weird. So they, are you telling me that Aetna will cover for someone that has tooth pain?

Maybe they’re getting a tooth removed or something? Yes, they will. Not. Through their dental insurance, through Aetna, they also covered TMJ conditions. Now that’s something unique to them, CIG. Has a much broader allowance of diagnosis. But do you know Cigna doesn’t cover TMJ yet? Aetna does. So here’s what I will tell you.

If you code within this range, they’re gonna pay you you code with these conditions, they’re definitely gonna pay you. Just be careful of maintenance treatment. Notice what they define as maintenance treatment. Maintenance treatment where the member’s symptoms are neither regressing or improving is considered not medically necessary.

So I’ll simply put it this. , so long as you’re making the person better, it’s medically necessary. Now, the difficulty is once they are better, should we keep treating to keep them that way? My opinion? Yes. However, from an insurance standpoint, they want them to have a fall off and when they do, can treat again.

So this is where you might see a patient periodically throughout the year for acute episodes of a chronic condition. It flares up, we take care of it. We do a handful of visits if they’re. A month later it comes back again. But will they cover it? The answer is yes. Now they’ve listed the conditions, but what are the codes?

So let’s take a look at these codes specifically. They cover headaches and it covers migraines. Now you’ll notice migraine headache is G 43 0 0 1 through G 43 9 19. So you can well imagine. Wow, there’s a lot of coats from migraines Now there’s not 900. There is about 35, but they vary between those sections.

The most common one, G 43, 1 0 9, that’s your standard run of the mill migraine. But does it cover migraines? It does. Does it cover tooth pain? It does, but look at the code K 0.89. I bet many of you’ve never seen that. That’s literally a code that says disorders of the teeth. But because there’s no specific code for tooth pain, we use this one to document that in the notes.

It’s gonna have pain, but this is the code you use. It will also cover arthritis, but notice it’s arthritis of the hip, the hip, the hip, the knee. The knee, the knee. So it’s covering hip and knee pain. Now, you know what frustrates me about that? If you can tell me that acupuncture is gonna help with the knee and arthritis, pain of the knee, or.

Why would that not work in other areas of the body, such as the shoulder or the elbow? I think it obviously would, but again, they’re specifically indicating here it does indicate TMJ disorders, so TMJ dysfunction of any type or pain notice, neck pain, and then the low back pain codes. Then of course, vomiting of pregnancy, vomiting, chemotherapy, headaches, and that adverse ad, adverse effect of anti-neoplastic immunosuppressive drugs.

And notice, parenthetically, it says chemotherapy-induced nausea and vomiting. The fancy term is adverse effects, but it’s just chemotherapy-induced nausea. One quick note, this code has a plus at the end. Please note that this code any, anytime it’s an S or a T, prefixed to a code, it always ends in an A for acute.

And then the last one says Other specified post-procedural status. This is the code for post-surgical pain. They’re specifically indicating it dental, but obviously if you’re using any other type of post-surgical, this could work. One quick note please. Everyone take note of this, this code Z 98.89, even though it was published this way by.

it’s incomplete. It actually should be Z 98.890. So do write that down. Z 98.890, not 89. It shows you that insurance companies aren’t always infallible as well. But here’s what I’ll point out. If you code these two Aetna, I am going to guarantee they’re gonna make payment because these are on their list.

In fact, at the very top it says, these are the codes. If the selection criteria is met, which means is it chronic pain in some areas or is it, you know, manifesting that way. But you’ll notice they do something tricky. They say, parenthetically not all inclusive. Now that frustrates me because what they’re saying is these are the codes we cover.

We may cover more, but we’re not gonna tell you. Well, what I will tell you is generic. There’s some additional things that they’ll cover, and two of them, one of them is really gonna surprise you. I talked about the knee and hip arthritis and pain. What I will tell you is arthritis wise, they’ll cover here.

They’ll also cover pain. I have found through many people that pain in a joint will be covered like shoulder, elbow, wrists, so you’re pretty safe there. What they will also cover surprising. is anxiety. Now not full on depression. We’re not coding that probably from an acupuncture standpoint, but anxiety, depression, unspecified.

The code for that is F, as in Frank, 41.8. Now I’m pointing these out the other joint and this, um, anxiety just to say these are some other services. Some of you may say, Hey, Sam, I build a few other ones and they’ve been paid well. Great. I would like to say, let’s look at those and make sure we all know what they are.

That’s why I gave you those three extra ones, meaning joint pain and then of course the anxiety. What I will focus on though is to tell you be careful of coding things they don’t cover by example. You’ll see here it says Cervi. . That means neck pain. Now what if you have someone that has a strain of the neck?

You know, they do something active and they strain or sprain the muscle. If you coach strain or sprain to Aetna, they will deny the claim even though it’s neck. So what should you do? Don’t coach. Strain. Sprain. What? What is the symptom? What are the complaints a patient will have when they strain their neck?

You got it. Neck pain. So in this way, you’re gonna use the more generic, just tell me where the pain is. Don’t get specific that it’s spondylosis or other things of that nature. I kind of like that. It does keep it simple, but here’s what I’m again gonna point out. Make sure you’re looking at this list and if it’s not on the list, Make sure that you can find someplace that, okay, I’ve seen this elsewhere been covered.

This is one of the things we do at our seminars. More importantly, our network service. When members call me or get in touch with me, this is what I help them with is that here are the additional codes they may cover. I wanna at least give you a thumbnail though, to see what they do cover. So when they say they have mandatory coverage, I’m gonna say, yes, they do, but it’s for these codes.

So maybe take a picture of this screen, make sure you’ve got the right ones. What do they cover? Well, they cover acupuncture as you can. Well see, you know, initial sets, follow up sets where they’re manual electrical. But you’ll notice it also says tending the TDP lamp. No specific code. It says, well, what would that be though?

That’s probably just gonna be your hot lap. 9, 7, 0, 26 notes. It also covers dry needling. Will it pay an acupuncturist for dry need? Generally, no. What they’re gonna cover you for is acupuncture. I’m not gonna say an acupuncturist can’t dry needling, but I would assume it’s more acupuncture. These are the things they’re gonna pay you for, and quite frankly, they have a higher value.

I’ve had people ask me, Sam, can I bill dry needling? Well, I guess you could, but here would be my point. Why would you? The value of the dry needling codes are 50% of the acupuncture codes. Why would I bill a service that’s 50%? Than the actual service I’m performing. So I would focus in on the acupuncture.

Think of it, and this is something I emphasize when I come to you as a patient or when someone comes to you, guess what they’re seeking acupuncture. Therefore, what should you provide? Acupuncture. That doesn’t mean you might not do a little body work or some other things, but notice they’re not indicating these are covered.

I’ve run into some issues also where offices have had some plans with Aetna that don’t cover the. Now if the plan doesn’t cover it, does the patient have to pay for it? Well, they would assuming you’re out of network. But keep in mind, what I will tell you they will pay is the acupuncture codes. Now, be careful, stick with the codes I gave you because here’s their list of things they don’t cover, and look how far this is.

We have acne, pancreatitis, addiction, aids, Alzheimer’s, all of these conditions. If you code any of. , it won’t be covered, but let’s take this one here. Notice it says myofascial pain. Okay. What is myofascial pain? Pain in the muscles in some part of the body. Well, what if those pain in the muscles are in the neck?

How would you code it for Aetna neck pain? What if they’re in the low back, low back pain, and so forth. So in some ways, these things can be covered, like by example, carpal tunnel syndrome right here. What does carpal tunnel syndrome cause? Wrist pain or forearm pain, that’s what we code. So be careful they’re not covering these things, but they may cover it if you can keep it symptomatic.

So while I will say, I’m happy to see this, I hope it gets better, this gives us a good framework so that way you’re not fooling yourself. One of the difficulties that I’ve run into offices is they’ll say, Sam, my claim’s not being paid in its Aetna. Then they send me over and they’re coding something that’s not on the.

and I say to them, let’s make a correction. So these are the things that I wanna make sure that you understand that you can solve that if a patient comes in with a condition that clearly doesn’t relate to any of those, you know what you’re gonna tell them. This is not covered by your plan. However, here’s what we offer for cash patients, whether you’re doing a pre-pay plan or just a discounted time of service, that might be something you can do.

But I don’t want a patient thinking it’s covered and it’s not. Cuz do you ever notice, sometimes people wanna blame. when you are, when their insurance doesn’t cover, how is that your fault? It’s not. Obviously it’s their coverage and so don’t give them the false sense that it is covered. This is what we do at American Acupuncture Council, specifically the network.

You want someone to be helped to you. I’m an expert. I could become part of your team. Join us. You can call me, you can email. We do Zoom. We are here to make sure you’re getting. Many of you have lots of problems of things that don’t pay you we’ll fix that. Take a look. Otherwise everyone, I’ll see you next time.

Until then, I wish you the absolute best and continue doing what you’re doing. Take good care of your patients.