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Acupuncture Malpractice Insurance – Are Your Exams Being Denied and Not Paid?

Well, today I’m gonna spend some time talking about valuation and management services or E and M codes or exam codes.

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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, the American Acupuncture Council. And of course you, let’s make sure your claims are getting paid, and I don’t care whether you’re doing cash insurance or otherwise. We always wanna make sure you’re doing well, we have a vested interest in you.

Well, today I’m gonna spend some time talking about Valuation and management services or e and m codes or exam codes. And I’ve recently had a lot of offices with issues of Sam, my exams are being denied or they’re not paid and they’re giving me excuses that don’t appear. Right? So let’s talk about that a little bit.

Does a patient require an exam? Of course they do. Well, let’s get into that. Let’s go to the slides. Let’s talk about what’s going on and getting paid for your e and m services. How do I get paid for my exams? And I use the term exams because. Often people will say e and m, and then they say, office visit.

And I want you to keep in mind an office visit is anything that you do when a patient comes in, they’re visiting your office. So keep in mind, office visit from your standpoint should just be the visit overall. It depends on what you do. So by example, on days you do an exam. That would be an e and m service, and you may do treatment the same as well, so be careful.

The term offices, it will often get you confused. What I’m speaking about for exams of course, are evaluation management or e and m codes. If you’ve all learned, and you’ll notice we have two types. The new patient, the established patient, you know, two oh twos to 2 0 5 for new 2, 1, 1 to 2, 1 5 for establishing.

What are these for, for the indication when the patient required an examination by you. To determine their diagnosis, their need for care, and so forth. And so we’re broken down into four codes for new patients, five for established, and they’re pretty straightforward. They just indicate how much time or how much medical decision making did you spend doing an exam.

You should be familiar with that. That’s not the hard part. Where we run into problems often is, I’ll get off the saying, Sam, I billed for an exam code. And I didn’t get paid. The insurance said it’s not a covered benefit or it’s included in something else. So what is it that’s required to do or get paid for an exam?

Well, let’s think of it. An exam is something that’s absolute required. If an insurance says that you shouldn’t do an exam or it’s not within scope, I can’t believe that not to be true. I mean, obviously when a patient comes in, what’s the first thing you have to do? In order to know whether you can help them, you have to evaluate them.

It’s required to determine the condition and their need for care, what’s wrong with them. And then of course, I would argue it is a ethical and legal requirement. Can you imagine the liability if you said, Hey, I don’t care. What’s wrong with you? Just shut up and lie on the table and start needling in you and go, well, we’ll see what’s happening.

I don’t care what’s wrong. Well, of course not. It is an absolute requirement that you make some level of evaluation, determine the need and necessity for care. So I’m gonna say it is an absolute requirement to do an exam, however, where the confusion comes in is how do you bill for it and how do you document it?

Well, let’s realize the one thing that’s probably the most common issue for acupuncturists being denied for exams. Is the failure to understand that every time you bill an exam code an e and m code with treatment, you have to put a special modifier on it in order to determine and to demonstrate it is separate.

From the exam associated with the treatment. So notice here it talks about the acupuncture services or procedures includes an e and m assessment. So in simplest ways, think of it this way, if you saw someone for the very first time, you are clearly gonna ask them lots of information about who they are, what’s their symptoms, what’s going on, what makes it worse, what makes it better.

In other words, you’re gonna do a pretty detailed history. You’re likely gonna do some physical exam things. Maybe it’s tongue and pulse, maybe palpation, range of motion, you name it, the many things an acupuncturist might provide. And then based on that, you’re going to determine a diagnosis and then begin some treatment.

Well, those things actually are somewhat included in the acupuncture service, but here’s where we have to be unique. Realize the acupuncture service does include . A small exam. Now, the first visit, the one I just described, is clearly different, above and beyond. But let’s talk about that first visit is one thing, but what about when the patient comes the second time?

Maybe I come to you two days later and you say, Hey, Sam, how are you feeling? Is that a little better or worse than last time? How much time did the pain resolve for you? In other words, you’re gonna do a little short exam that includes a little history, maybe some findings such as, you know, uh, tongue and pulse again.

And then begin treatment. So there’s what we call a pre intra and post-service evaluation associated with treatment. So here is the number one reason most acupuncturists are denied for exams. You forgot to tell them this exam is above and beyond what I normally do as part of the visit. It’s a true examination and we have to put modifier 25.

So if you’ve been denied for an exam and you’re not familiar with 25, that’s probably the number one reason that modifier is necessary to indicate to the carrier that this examination was separate and distinct. Therefore payable, no modifier, no money. Now, why is that? Because you’ll see here, there is a pre-service associated with treatment.

When they come in the second time, you’re gonna do a little review of their record, a little record review, face-to-face time with them, do some evaluation things, get them set up for care, perform the care, and even after the care, you’re gonna evaluate, Hey, how are they doing? Give them some recommendations for at home.

And this is why it says specifically in the CPT Manual. It says what you see at the bottom here, it says, additional evaluation and management services may be reported separately if and only if the patient’s condition requires a significantly separate identifiable e and m service above and beyond the usual pre and post service work associated with care.

So in other words, we’re saying, no, no, no. This is not the one that we do day to day, but this is the one above and beyond. So to come full circle with that, when is that necessary? Well, clearly the first visit. There’s no doubt a first visit should be separately paid for an exam and we put a 25 ’cause that’s clearly above and beyond what you would do on a follow-up.

Now, when would it become necessary again? Now, some of you say, well, Sam, I do an exam every day. That’s exactly what we’re pointing out here. You do and we understand that, and a little bit of that is associated with the treatment. Keep in mind, that’s not only true for you as an acupuncturist, that’s true for medical doctors, chiropractors, physical therapists, anyone that’s doing this type of care.

Would have the same provision. So they have to put the modifiers as well to show that it’s separate. So we have to make sure it’s above and beyond. So it says here if and only if it requires a significant one. So the day-to-day one, you do for, you know, several visits after, not really, but when would it be appropriate?

Certainly every 30 days. Now why every 30 days? It’s the standard. It’s the one set up through Medicare that all insurances have adopted. So an exam on the very first visit. When every 30 days absolutely reasonable should be payable. Just remember, assuming there’s treatment, put a 25. Well, what if you say, what if I don’t put a 25?

You won’t get paid. Now, you don’t need a 25 on the day-to-day one, but on the one that’s exam, so the first visit. And then about every 30 days. Now, some of you say, I like to do it every six visits. No, it’s every 30 days. Whether you do 12 visits in 30 days or six, keep in mind it’s about 30 days. Now, there could be instances.

What if the patient says, Hey, last night I fell down and I hurt my back. Would that be appropriate to do a separate exam from what you were seeing them before? Let’s say it were headaches. Well, of course, because there’s something new or significant that’s above and beyond, so make sure it has to stand out.

In other words, make sure the exam clearly shows that this is not the routine exam, and that’s probably the number one reasons things get denied. So simply put, when you’re billing, put a 25, notice this example here. You’ll see 9 9 2 0 3, that mid-level exam. But because there’s acupuncture performed the same day.

We put the 25 modifier on it. The 25 modifier does not change the price. It’s still gonna be paid the same. It just indicates that it’s payable. There is no reduction in doing that. In fact, in many ways. I wonder maybe should that have been the second thing you’ve learned in acupuncture school? I mean, the first thing, of course, how wonderful the profession is, all the things you can do.

But can you imagine how many of you finished school? Never learn this one simple thing. And then of course you get out and you’re frustrated like, how come I don’t get paid for exams? Well, because you didn’t put the proper modifier. Now let’s keep in mind, I’ve had some offices though, that are saying, well, Sam, I know that I’ve been doing that and these insurances still won’t pay.

So what I’ve done here is I’ve taken a page. From the CPT book, I just took a picture of it. Put it up here, and here’s what it says. Notice it says, evaluation and management services may be reported in addition to acupuncture procedures when performed by physician or other healthcare professionals who may report them, which means you.

Now we move down a little bit here and we’ll get into this section here and it says it may be reported separately using modifier 25 so long as it’s above and beyond. So I wanna make sure if you ever get a carrier that’s saying . You shouldn’t be able to. I wanna point out the CPT manual clearly says it.

This is not unique to you. It says it the same for chiros, the same for medical doctors and so forth. So it is absolutely appropriate. However, there are some plans that come back and say, no, we’re still not gonna pay. So let’s talk about how to deal with if it’s denied, was it billed properly? Would be the number one thing.

Did I put modifier 25? That’s probably the simple one, but sometimes you’re gonna say to me, Sam. I did put the modifier 25. It still came back and it stated the exam was included in another service. What you’re gonna do is push back and say, excuse me, this was done on the first visitor every 30 days, and there was clearly a separate and distinct service, an exam that was above the routine day-to-day visit.

So you’re gonna push back on that and basically point out to them it was separate. That’s why we put the 25. But here’s the bigger problem sometimes. It’s because you have a contract. It’s why I will warn you. In fact, how many of you have worked with me directly? one-on-One to know whether or not it’s worth it to join some plans.

I’m not gonna say never, ever, but you wanna make some better choices. ’cause sometimes when you join these plans, you join ’em and think, great, I’m gonna get more patients. Do you know many of your contracts say we don’t cover exams? So the reason it may not be covered, it’s part of your PPO reduction.

It’s basically saying, we’re gonna send you a lot more patients, but we’re not gonna pay for the exam. You have to make it a business decision. Is that worth it to me to get less money, but maybe more patience in some instances? Maybe, but for me, mostly, probably not. So what if the issue is part of your contract?

Is there a way to dispute that? No. That’s the contract you signed up for. Now, maybe you might decide not to be part of it. This is why. Think of it. If you’re just a cash office, isn’t your first visit more expensive than a second visit? Think of that for a moment. Why is that? The first visit has an exam, but here’s the issue we’ve been running into, and I know a lot of you on the East Coast, I’ve done seminars there up and down the East Coast from New York, down to Florida, that the plan says an acupuncture provider is not paid or may not even do an exam.

We’re running into this into New York quite a bit, and my answer to that is, excuse me, you’re saying an acupuncturist cannot perform an exam. Would that not be against. The rules of just engagement of a patient. Can you imagine the liability if a doctor said, oh, I didn’t examine them. I don’t care what’s wrong with them, I just treated them well, how could you treat someone without evaluating what is wrong and knowing what to do?

So there’s a lot of pushback on that. If that’s what you’re running into, please get part of your state association. Join us in fighting to say, excuse me. Of course it is part of your scope. In fact, what I’ll tell you is look at your scope of practice. Does your scope of practice indicate an evaluation?

I’m gonna guarantee it does, at least at some level, so therefore should be payable, so be careful. I think what’s happening is some payers are finding, hey, acupuncturists will just go away if we tell them no, we’ll just pay for treatment. We don’t wanna pay for an exam. My goodness. No. If you’re doing an exam.

It’s necessary. Of course, that’s payable why it takes time. It takes effort to do it, so make sure that you’re always pushing back. However, please be sure if you are billing for an exam, and I don’t care whether it’s cash or insurance. By the way, is there clearly more information and more details that would show this visit had a distinctive exam?

Keep in mind if you’re billing for an exam, there needs to be an exam above and beyond, just kind of like acupuncture, and we’ll talk more about this coming up in the first of the year, but how are you documenting it? How to make sure you’re avoiding anyone coming back, saying the services weren’t properly described.

Not hard, but there’s things you have to do. Have you ever had help with that? Have you ever understood it? Maybe not. That’s what we do with the network. It’s not just about practice and making more money, but making sure we’re compliant. All those factors, I want to help you with that. That’s what we do with the network.

We do the education. Come to a seminar first of the year, you know what’s happening. There’s updates to these e and m codes. Nothing major but enough that you want to be aware of. To know which code to properly choose, and there’s some additional codes that are updating as well. We always want you to be in the know.

The American Acupuncture Council is your partner. I’m your partner. Your success is ours, and I wish you well. We’re always gonna be there as a resource. Take a look at our website, there’s our phone number, come to our seminars. We’re here to help everyone go out and do well, and I wish you a really good New Year and prosperous new year.

Thank you.


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