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Get Claims Paid The 1st Time You Submit Them



But let’s talk about making sure that when you are dealing with insurance or dealing with claims that you’re not getting these common errors and common denials that are so frustrating because we wanna make your life a little simpler.

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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, the coding and billing expert for acupuncture, the American Acupuncture Council, and you the profession. As always, we’re trying to make sure your claims are getting paid. You can make your life a little simpler and more profitable. and you can do what you like to do, which is care for patients.

But let’s talk about making sure that when you are dealing with insurance or dealing with claims that you’re not getting these common errors and common denials that are so frustrating because we wanna make your life a little simpler. Again. I want you to be able to treat patients. Let us take care of the billing part.

Let’s go to the slides. Does that talk about common denials and how to correct them? What goes on for acupunc? Why do claims get denied? What are some of the common things that we see? The most common thing that I run into, and I deal a lot with this, I lecture every year to thousands of you, many of you’re members of our network service, and one of the issues we run into, you’ll get a denial that says, The plan is not covered and you think I did the verification.

How is this not covered? What happened? One thing I want to really implore you to do is make sure you understand the coverage the patient has. Often you will see coverage that will say, we cover acupuncture, and you think, great, you’ve verified it. They cover acupuncture. Then you send a claim and it comes back denied.

What do you do? First I’d look to make sure was it really covered or ask this question. If there’s coverage for acupuncture, must the provider be in network? A lot of plans do have acupuncture benefits, but only for providers who are in their network. So don’t be confused. Often you’ll call and hear all these great answers like, is acupuncture covered?

And when they say Yes, you hang up, or you hang up and say, great, that’s phenomenal. Then you send a claimant, it’s not paid. It’s because you didn’t ask that other. is the coverage for in or out of network providers. And then I would further ask this question, do you see my office as in-network or. , if you’re out of network, is there no benefits?

So let’s often make sure that the plan, you know what it’s covering. Also know the types of coverage that it has. What does it cover in the sense, does it cover acupuncture alone? Does it cover therapies? If you do therapies? So be careful. That is a common area of denial. Make sure you verify the coverage.

The other area that we run into lots of problems with are claim forms. We’ll get into those specifically, but how to fill it out. None of it is very. But there’s a couple unique things. If you don’t do correctly, will commonly come back and it’s very frustrating. What about just improper diagnosis?

That’s certainly an area improper use of A C P T code, if you will, but also just missing a modifier and you’re gonna wonder what modifiers do I need to do? Don’t give you a quick primer on that today to make sure we’ve got the right information, but also make sure you don’t run into the one where it says insufficient document.

Is, do I have enough information to make sure the claim gets paid well? Let’s talk about claim forms. What are some of the common things that I run into that offices have? When someone comes in, they’re gonna present an insurance card, and on that insurance card we’ll have their information for the claim.

That’s what goes to the top part of this claim. Whether or not it’s a standard or group health insurance plan, or maybe it could be Medicare under some circumstances, but nonetheless, check that off properly. But the bigger issue. Do I have the patient’s name proper? Please note it says here, patient’s name, last name, first name, middle initial, whatever it is, make sure it’s exactly as appears on the insurance card.

So often I’ll see denials because the patient will have a name that they’ll say, oh, just call me Patty. When on the card it says, Patricia, don’t put nicknames. Also, make sure you’re putting the exact insurance ID number. We will often see numbers transposed. Because it just goes in and makes a quick error.

So do make sure now, once we’ve got that set, that ends it, but it’s nothing more frustrating going, wait a. , what information do I have to have? And this is often concerned. Many times it’s gonna be the patient and you’ll indicate self, but what if it’s the spouse or the child? Often you’ll put the patient’s name here, but if the name is different on the car because maybe it’s a child or it’s the spouse’s plan, remember their information goes here as the insured’s id.

so be careful. Sometimes the patient may be different from the insured, though they’re both insured. It depends whose name is on the card. So don’t run into that common era. But here’s a big one that comes up quite a bit. What about block 14? When you’re filling out the 1500 form and block 14, it says, date of current illness.

And so many people look at that and say what does that mean? What do we put in? Were you gonna put the date generally of when the patient had the first symptom and or an injury? But often you might say This patient had an injury or this pain has been there for years. Obviously if I put something 20 years ago, they’re thinking why are you putting that date down if it’s a very old date, or it’s a type of a chronic condition that continuously flares up?

Always update this date to the date where the patient presents to the office. So it doesn’t always necessarily have to be a date of injury. It could be the date of the first visit, but do make sure it’s completed and put in this area. And one quick note, if you’re billing Anthem, Anthem is a little bit weird.

Anthem wants the date of the first symptom here, but they also want to block 15 the date of the first visit. So this could be a week ago, and this is today’s date because it’s the first visit. And then the qualifier you’re gonna put there is 4 54. I know a little bit odd, but 4 54, that’s gonna be Anthem policies.

Anthem policies seem to require that a little bit more than anyone else. Now, again, just Anthem. Now the other area that I commonly see, and this is really a big issue for acupuncturists, is not having a complete code. Do make sure if you’re using coding, make sure that code is complete. Often you might be using a code that’s a little bit old.

Remember, codes do update. Some codes are three digits, some could be as many as seven. So please make sure if you’re using any coding, assure your codes are correct with a number of digits. Notice this one for just pain. R 52 is just three characters, yet this sprained strain. Is all the way up to seven characters, so do make sure it’s the proper one.

But here’s one to keep in mind though. , it’s more important to know what codes are gonna be payable for acupuncture, and this is where things get tricky. Last time I did this class with you, we talked about specifically certain types of insurances, specifically Aetna, on what they cover. Let’s look at a few other ones.

Here’s the company, American Specialty Health, and as you’re aware, well aware, they manage a lot of particular companies, particularly Cigna, some of the Blues, some Aetna plans as well. And they use what I call , I don’t know, physical therapy or chiropractic end of coating for acupuncture in that they want the neuromuscular skeletal type pain things.

Notice the things that they cover, headaches, hip or knee pain with osteoarthritis, extremity pain with or without osteo osteoarthritis or mechanical irritation, and just other syndromes related to the joints in muscles back and neck pain. So you’ll notice that’s not including like abdominal pain in other internal symptoms.

It’s really musculo s. Except for nausea and vomiting. So no, for this plan, if you were to code abdominal pain, not gonna cover, but if you code low back pain, it will. Now also, keep in mind, some things could be tricky. If you’re ever dealing with a Medicare advantage plan, common denials are because you’re using the code thinking, oh, I need low back pain and put M 54 50, when in fact, for the Medicare plans, whether it’s Medicare, part B, or.

You have to have M 54 51 or M 54 59, so it’s good to understand the nuances of what’s covered. Here’s an example of a course, the one we went through last time, which is the Aetna plans. These are the codes they cover, which tells me if you bill these codes, they’re gonna pay you. Bill something not on the list, they’re not gonna pay you.

So it’s important to start to learn the nuances of what codes are covered or not covered. That’s one of the things that we cover in our seminars. Or more importantly, if we do one-on-one as a network member, I can go over with you. Here’s what Health Partners has, here’s what UnitedHealthcare has, cuz it’s important to know what codes are payable.

Nothing’s more frustrating thinking something is. and it comes back not covered all because you didn’t understand the codes that they require. Another area that commonly comes back is that hey, I build for four sets of acupuncture. . They only paid me for three. What’s going on? Or sometimes, maybe they paid me for one, depending on the plan.

Under the standard rules, and this is across the nation if you will, there’s something called the medically unlikely edits. And what, these are the maximum number of services that are payable per a visit, and this includes all types of chiropractors, physical therapists, and so forth in every code or service.

Has a maximum number of services or units that they will allow. In this case, for acupuncture, it is three. They allow up to three. So if you bill more than three, they’re not going to pay it. They’re simply gonna bundle it. So do keep in mind it’s three, I’m sure you’ve seen as if you’ve ever dealt with the va, Cigna, United, and many of them.

Now, are there some plans that may be. Sure I’m familiar with plans out of New York, particularly New York ship that will generally pay up to four. So I’m certainly gonna say, bill, what you do, but do understand some plans will max out at three. So that denial is simply one of just fruition. They just don’t allow any more than that.

So again, if you’re billing more than three, that could be an issue. The other issue for acupuncture though, Modifiers and denials. So you notice here’s a claim form someone with simple back pain. But notice there’s the acupuncture codes billed, but then notice there’s modifier 25 on the exam. This is probably the most common denial I get for acupuncturists, is Sam, they didn’t pay for my exam.

The first thing I’ll ask you is, did you bill with modifier 25? And most of the time the acupuncturist will say to me what do you mean by modifier 20? As soon as they say that I know the reason. Remember, anytime you bill an. With your treatment, any treatment, you have to put modifier 25 on the exam code because this demonstrates that this exam is above and beyond the day-to-day evaluation.

In fact, what it means is what’s printed in bold here, if and only if the patient’s condition requires a significant separately identifiable e and m service above and. The pre-service and post-service associated with treatment. Remember, acupuncture or treatment includes a little bit of an evaluation, so every day there is evaluation.

It’s small, but there is, Hey, how are you feeling today? Is it better? Is it worse? Maybe you’re doing some palpatory findings, tongue and pulse. That small exam is embedded into. the acupuncture code, and that is the reason we put modifier 25 is cuz what we’re stating is this exam is above and beyond what we do on a normal day to day.

and therefore is payable no 25 no money. So make sure it’s there. Now what about a plan that doesn’t cover an exam? That might be a bit unusual, but it depends on your contract. What if you’re contracted with a company like a UnitedHealthcare under Optum, where they pay you per diem? They don’t pay separately for exams because they bundle it all as one payment.

So do keep in. That sometimes it’s a contract issue, but other times it’s just the fact, did I have the proper modifier? Now, you’ll notice none of these other codes have any modifiers on it because it’s not needed. However, what about this last 1, 97, 1 40? I know some of you’ll say I wanna put modifier 59, truthfully, a modifier 59 to indicate a separate services never needed.

However, you will need for some. Modifier gp. Now, this is why I think sometimes acupunctures go, I don’t know if I wanna do insurance at all. It’s just too much hassle. It really isn’t. It’s just understanding the nuances of it. Once you understand it, it’s not hard. So now here’s the rule. If you’re billing United Healthcare, You’re gonna put a gp, G as in George, P as in Paul at the end of a physical medicine code.

So that’s all physical medicine codes, whether it’s from heat all the way through the unlisted service, but massage, manual therapy, you name it. And it’s gonna go on all of these payers, UnitedHealthcare, that includes Optum Health and everything affiliated U M R U P M R, VA claims will. Anthem requires it.

And if you’re in California, here’s a weird one. Blue Cross of California, not Blue Shield. And of course, any of the Medicare plans or federal plans you may do. So again, think of it, a denial will come back and you’re thinking, why didn’t they pay for a therapy? is because you were missing the modifier when it’s one of these policies.

So do keep in mind, focus in on making sure that I have the claim form right, and that’s one of the things I help with. That’s why I’m an expert. I’m here to help you to make sure that you do well and that’s what these short courses are for. Now, one thing to keep in mind, you’re thinking if I’m gonna put a GP.

I’m just gonna put a GP for everybody. Nope, do not blanket it. Don’t include it for plans that don’t require it. Only the ones that I’m showing here. And here’s the final thing I’ll get into is that it’s just INS insufficient information. And you’ll notice here it says, according to 9 7814, it’s not supported.

The medical records submitted do not indicate the needles were inserted and does not indicate the face-to-face time. Now this is something for another course, but do keep in mind if they look at your. Can they tell what you’ve done? Now, here’s something interesting about this claim. You’ll notice the initial set is paid.

They’re saying it was supported, it was the follow-up set. So you gotta start to look at your notes and go, wait a minute, do my notes demonstrate what I need? Do I have the face-to-face time? Does it meet the minimum standards for each individual set? So that includes first set in multiple sets. And again, we need the time face to.

As well as the points of insertion. None of this is hard. Let’s face it, it can seem daunting if you’ve never done it. Once you get a good feel for it, you’re gonna go, wow, that’s really easy. I want you to think of, you sometimes will say, I don’t think I want to take insurance, cuz there’s these hassles. Do you realize the majority of people have insurance and they have acupuncture coverage?

Don’t you think they’re gonna want to use it? I want to give them access. What I have to do is make it simple. That’s what we’re here to. That’s what these courses are for. And that’s it. If you wanna really get some one-on-one help where we work together, we zoom directly one-on-one. You can even go to our seminars for free.

Take a look at the American Acupuncture Council Network. We’re here to support you. Your success is ours. Until next time, my friends.