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Does Your Documentation Match Your Services?



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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. Welcome back in. Thank you, American Acupuncture Council. Let’s make sure the profession continues to understand its growth and its potential. One of the issues I deal with a lot is documentation and coming from being the acupuncture coding and billing expert, I get this lots of times.

I recently had a call from a special investigator. From the Department of Banking and Insurance in New Jersey, I’ve dealt with this in Florida, California, and frankly all over to some extent, and it’s about documentation of acupuncture. Now, frankly, I don’t care whether you’re billing insurance, you’re doing cash, doing a combination, you still have to have your information documented.

It’s not very hard, but what you may have learned has been updated. And one thing to keep in mind, acupuncture is a profession. It’s not a perfect meaning, it’s a practice. You’re always learning and updating and one of the things you have to keep in mind is things have updated and I think there’s a lot of misinformation when it comes to acupuncture documentation, which I will go back and say, not very hard, it’s what you do, but have you ever really thought about what does it require that I have to have down?

Whether you agree or disagree with some of the aspects, frankly doesn’t matter. ’cause we have to go back with what is the standards set aside by law. And of course the profession itself. So let’s go to the slides. Let’s talk about Accu Acupuncture documentation, and let’s talk from it this way. We want to assure your documentation simply matches the services performed.

What if a patient makes a complaint that you didn’t, you charged them too much for the services they did. This is cash, and your notes have to back up what you’ve done, or it’s an insurance or any aspect in that way. So don’t be cavalier thinking that, oh, I don’t take insurance. I don’t have to document.

Not at all. I. Your liability is such that if you didn’t document what you have performed on that patient, it didn’t happen. So let’s assure documentation matches the services performed. Here’s one of these insurance claims that I get. A lot of these, because obviously people are billing insurance. It pays well in a lot of aspects, but you get back saying, we’ve looked at your notes and they weren’t well done.

Now, some of you may know I’m actually on the board. Or what’s called the Coding and Reimbursement Committee for Optum Health in United Healthcare. That doesn’t mean I work for them, by the way. It just means I’m an appointed member that oversees things. And one of the things we commonly run into that are problem for acupuncturists is just improper documentation.

In fact, in many ways, acupuncturists for documentation are low hanging fruit because often it’s never been learned or taught. How to properly document. So take a look here. What does it say? This office is billed out an initial set of acupuncture and it says the information submitted. This means your chart notes is, does not contain sufficient detail.

The submitted records don’t support. 9 7 8 1 0 was performed. It goes on to say it for the second set. Claim cannot be processed as billed. The code requires a proceeding procedure code, which means this one, and it’s not supported. We see this time and time again, not just with acupuncture. Here’s some more of that.

The documentation does not support the services billed. In other words, if you’ve collected money for something, you have to make sure you’ve shown you’ve done it in a way. This is a receipt, if you think of it, your documentation is a story, but a receipt or indication of what was done on the visit and the results of it.

So over and over we see this. Investigational services, but notice here, services not rendered as billed. Just simply documentation. Take a look here for 9 7 8 1 1. What it says is the each additional 15 minutes of one-on-one service, there are multiple examples where there’s conflicting information with respect to the time spent with the patient, and in fact, notice this one, 42% of the claim lines had no supporting documentation.

Just writing a date and saying they had acupuncture is not sufficient. Again, I want to emphasize, This is not about insurance, it’s about what’s documented about your patient, what was provided. So let’s take a look. What does it say in C P T? What do we have? Now? Keep in mind these codes have been in place for 20, or excuse me, 18 years, ’cause it’s 2023 and they’ve been in place for 18 years.

When I see people not understanding this, it frustrates me. ’cause I’m thinking when did you graduate in the seventies? So take a look. It says acupuncture, one or more needles. So what does acupuncture require? You insert needles if you don’t put needles in. It’s not acupuncture in the sense of a billing code or a service, so you have to put needles in, and then it says, With one-on-one time.

In order to put the needles in, you have to spend time with the patient. And acupuncture codes, as I’m sure you’re well aware, indicate 15 minutes and you’ll see this time and time again. The initial set needles in 15 minutes, the additional set needles in 15 minutes. So this is not unique, it is not new, but it’s something we have to make sure that we have.

So again, taking a look, needles time and needles. Now I think we’re often, we get confused is do I actually have to write the time down? Yes. If you are doing a service that is time dependent, there has to be time somewhere. Now, here’s the good news for the profession. Acupuncturists, I would say in my experience, and I’ve been around this 25 plus years, probably spend more time with their patients.

I. Most other providers, partly because the service you provide is very specific for time and things you’re doing, but also because of the things you have to evaluate, realize all of that is included. So what I want you to think of is what time am I documenting? Literally, if you’re doing acupuncture that day, the time starts as soon as you walk in the room and say, hi, Mrs.

Jones, how are you? It starts. So you’ll see here it says, how is the 15 minutes of time defined? Let’s make that larger so it’s easy to see. The 15 minutes of time for acupuncture includes lots of things. Basically everything you do when you contact the patient soon as you walk in. This would include a review of the history, so you know when you walk with room and say, Hey, how are you feeling?

Is it better today or worse? What’s happened over the last few days? That time counts towards acupuncture. It includes your day-to-day evaluation. Some of you may do tongue and pulse. Some might do range of motion. You might do some other testing. That’s all fine. It’s included your day-to-day. How is it feeling?

How is it better or worse? Notice, hand washing, sanitizing your hands, choosing and cleaning the points, quite frankly. Opening the needles, getting them ready to be put in the patient. All of that counts as well as the time it takes to insert the needles, making sure they have good grasp. You’re in the right point, making sure it’s all good.

Actually asking the patient how that feels would include. So that includes inserting, manipulating. Now, what doesn’t count is once you’ve put the needles in and the patient’s just laying there to rest without any interaction, that would not be considered part of it. But let’s say the patient is on the needles, but while they’re on the needles, you’re manipulating them.

That would count, but what also counts is the time that you’re in the room, again, removing the needles. Including notice here, completion of chart notes. So removing disposal. So I want to keep in mind time, just tell me when you’re in the room with a patient doing anything that’s part of acupuncture.

Now an exam is separate or if you’re doing another therapy, but the majority of what an acupuncturist is providing a course is acupuncture. Tell me the time. The only thing that really doesn’t count outside of the exams and therapies is the time the needle are retained. Isn’t included because that’s not something you’re time dependent by example.

Not unusual. I know the acupuncturist I’ve been to often I’ll have neuros needles inserted and I’ll lay there 10 or 15 minutes relaxing, maybe listen to some soft music or something of that nature. Nonetheless, that time doesn’t count. So here’s what we have to document. Don’t make this hard document the time and the needle.

So here’s two examples to, and I’m gonna give you a couple of examples to try to give you a feel for what you want. Now realize . There’s gonna be many ways you might do this, but it’s gonna fall somewhere in this range. Notice here it says clearly treatment or needle set one. I would prefer that you indicate which one is set, one or two.

If you’re doing multiple sets, say it. Say this is set one notice here. It’s indicates face-to-face time. So here it says 20 minutes and it says what needles or what points were needled. It lists all of them. And notice it actually indicates there was estim added to these two points, U B 62 and G B 34.

So that means that this set, because there’s electricity at it, becomes an electrical set. Nothing more complicated. It doesn’t have to be every needle, just even two. So notice what it does time. Points. Notice, it does indicate, Hey, the patient was rested on needles for 12 minutes. That’s fine. Now what if you just stay in the room with the patient and you’re continuously needling?

That’s all face-to-face. We just have to decide what’s points were in the first 15 and second 15, but nonetheless, showing here time and needles. Not complicated. Get in that habit. Notice it says here, after the patient rested with needles, they were withdrew and repositioned. Now let’s keep in mind, do you actually have to withdraw the needles?

I. To insert a second set. No. You may or may not. I’m not gonna say one way is better or otherwise. Obviously, I guess if one is a front side set and one’s a backside and they’re laying face down, face up, probably, but outside of that, no. They don’t necessarily have to be removed. In fact, commonly when I’ve been in, and I can again leave my own experience, I’ve had needles inserted and then just additional ones were put in, that would be a second set as well.

But notice how it’s documented. Treatment set two. Face-to-face. Time on this one is 18 minutes. What points did we needle notice? They added some ones with electricity. So clearly. Was there enough time for set one and set two with the points documented? Absolutely. So start thinking of how am I gonna do this?

Whether you’re doing paper notes, electronic notes, simply tell me your time in the room, face-to-face with a patient doing something that’s part of your acupuncture, along with the points you’ve inserted. Not very hard. Now you may question what about time? I did a program on that. If you’re not familiar with the 15 minute and the eight minute rule, go back in the R archive.

We have that listed there. But here I just wanted to make sure. Notice how simple that is. Don’t overcomplicate that. What you don’t wanna do is say I needle the following points and say I spent 30 minutes. Because if I do that, am I dividing into two sets? Make sure that it’s clear that what needles were in setted for set one or set two, or during that period of time.

Here’s another example. Now this is a full chart note. You take a look at that, but I wanna focus on just the documentation of the acupuncture. Notice what this one does. Pretty much the same thing, but just done slightly different. Notice it says each set of acupuncture is set one, two, and three.

It says the points that were inserted or reinserted. So it’s real clear that there were needles inserted. It tells you the face-to-face time, and if there’s separate retention, it does it. So notice this one. It names three points, the time spent. Now you might think we’ll see ’em. Come on. It wouldn’t take me 25 minutes to insert three needles.

You may think so, but realize the insertion of needles is not just the physical time of inserting the needles. All the things that you do with the patient to determine where you’re gonna put those points. The time to clean your hands, put the needles in, make sure there’s good grasp, realize all of that counts, including, let’s say, when you come back in the room, I.

To remove them. So notice each set clearly set aside for each one and time. Now, notice the other one said it spent 18 minutes or 20 minutes. Notice this one says, from, and two, frankly, it doesn’t matter according to C P T and the standards. So long as you indicate whether it’s minutes or from, and two time, it’s acceptable.

Just make sure it matches what was billed. So I’ll say to you, don’t overcomplicate this. Don’t be confused because well, in school I was told this or that. Again, sometimes what you were taught in school may have been old information. Or let’s face it, we all have biases. So what if you had an instruction that goes I disagree with it.

I will tell you, I don’t necessarily have an issue with someone agreeing or disagreeing, but I do have to go by what does the law and the rule state. So long as you’re within that. This is not hard. In fact, I would say to most acupuncturists, the one thing that I think most acupuncturists take pride in is the amount of time you spend with your patients.

Document it. It has value. You’re inserting needles. It all counts. We’re here to help realize, this is what I do on a day-to-day basis, is helping offices deal with problems to say, let’s take a look at your notes. Let’s make sure they’re okay. That’s what we do with our network members. If you’ve not been familiar with it, take a look.

Also note, we have seminars upcoming coming soon, because remember, October 1st, I C D 10 does update. There’s gonna be some new codes out there that are specific to acupuncture providers, so always know that we’re gonna be your resource. The American Acupuncture Council Network is your place for seminars and for day-to-day help.

Take care everyone. . .