Let’s talk about what’s going on with recoupment and standard episode of care specific to acupuncturist and frankly non-physician providers.
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Greetings, friends and colleagues. It’s Sam Collins, the coding and billing expert for acupuncture, the profession, of course, the American Acupuncture Council. Of course, I’ve got a little update coming up because obviously many of you have been contacting me, network members, and even others have contacted me.
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Say, Hey, Sam, what’s going on? I notice. That they’re not paying for exams and they’re also still recouping. We’re gonna talk a little bit about that, but we have to update from what we did in April. So let’s go to the slides. Let’s talk about what’s going on with recoupment and standard episode of care specific to acupuncturist and frankly non-physician providers.
So you’ll see here is a letter dated June 23rd from Tri West, and it says, we received the above claim. Let me bring it so I can pull it up. And it says. Try West. Receive the above-mentioned claim for your often notice I highlighted in yet it says evaluation and management procedure codes are not paid for this rendering provider specialty.
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This is the latest thing we’re seeing. It appears, and I’ve seen it absolutely published way that to me would make it more, but it appears they have taken the ability for acupuncturists to be. Separate exams when it comes to the va. That of course is very frustrating because of course is an exam necessary thing.
Of course, I to determine the need for care you to determine the continuation of care. So what’s occurring, I think is maybe A-D-O-G-E cut here that they’re eliminating the payment for exams. That doesn’t mean you don’t need do one, they’re just not. For it. I think it’s probably we’re seeing the patient for the overall payments, but they’re not covering it.
We’ll see directly. Now the word that they did this in ap, what I’ve seen Pub in their newsletter is not quite clear enough for me. So I’m waiting to see the full publishing and episode of care, but I’m sure many of you have met. Now. Here’s gonna be the pushback if the exam after April when they published it.
They’re gonna be damn behind it because published, however. But then I want you all to think of standard episode of Care for Acup Occupy. Whenever you notice the standard episode of care, you’ll notice whether it’s going to be initial chronic follow-ups. They include e and M codes. You’ll see really, 9 9 0 2 to 2 0 5 9 9 2 1 to 2 1 5, and I bet probably your authorization as well.
So my argument’s gonna be, they’re saying they’re not gonna cut well if it’s after April, send an updated authorization’s not listed. I’m waiting to see that, then I would say, okay, but if it’s prior dispute’s gonna be, how did you send me an authorization? Clearly indicates exams and they’re, now, I’m not gonna pay for it now, it appears after April.
This is gonna true. But prior, it’s gonna be a pushback. Now that very frustrating. Of course it is. But I’m gonna ask you, is it worth it to still be part of it? I do, because think of the overall payment on a VA patient. You’re getting 12 visits to start, probably eight and eight to follow up. Assuming you’re doing three sets of acupuncture and a therapy or two, that’s maybe 110 to $150 of reimbursement.
Am I going to take away potentially, three to $4,000 a payment? Because they’re not gonna pay for a couple of exams. I prefer they do, but I’m gonna say I’m not gonna go that far. It’s something I think though we’re gonna be fighting. I shouldn’t say think. I know we’re gonna be fighting as a profession on a national level along with chiropractors and physical therapists, because this affects them too.
Because this goes against the equality provision. Equality says that if it’s within scope and you pay, other providers have to pay you because this is not Medicare. Now that’s gonna be a little bit of a fight, and that’s not gonna happen in short term. So when you get this, I do think we should dispute it.
I would certainly push back if it were pre-AP April, that they should, if it’s after April, not so much. Of course, if you’re a network member with me, reach out. We’ve got some letters for that as well. But I do wanna highlight also beyond that, just a couple of quick updates. Let’s talk about what’s happening and what’s gone on with doing.
Things with 9 7 0 3 9 or 1 3 9, and that’s of course what a lot of offices have used for cupping. Remember that was removed more than a year ago, so please do not use that code for cupping. It is not appropriate. Do not list it. They may pay it, but they’re gonna recoup it. So do not, if you’re gonna do cupping, use 9 7 0 1 6, which is a vaso pneumatic device.
It’s not a high payer. It’s about 11 to $15, but at least you are being paid for it. But again, do not use 9 7 0 3 9 and if they are recouping that, if it’s pre 2024. I would argue they can’t, but if it’s after 2024, they can. Now some people have argued. What about statute of limitations? Statute of limitations, I would argue certainly does apply.
Unfortunately, you know what I’ve realized or what I’ve learned, the statute of limitations for the VA is actually six years, so we’re not gonna win on that one as far as this goes. The other thing here is, and this has come up recently because obviously a lot of you are using paint indexes or similar.
To verify how the patient’s improving. I recently had an office, or actually a few that they were denied few further care because they weren’t showing at least a seven point difference on the general pain index. I really like the general pain index. It’s certainly the similar to the pain interference.
Make sure though, if you’re using it. If you’re doing it once a month, there’s gotta be at least a seven point change to be considered significant. Now, most of you, I hope, are getting bigger than seven point changes, frankly, but if you’re not realize it’s going to be a problem ’cause they’re gonna push back, which means you also have to focus in what if I’m using the pain scale?
That also has a limitation, which means it’s gotta be three points or more. Obviously if I say I’m a seven, I go to a six. That means I’m better, but it’s not considered significant. So if they start at seven, the next time you do it to really be considered significant, say on re-exam, it’s gotta be four.
So a three point difference, I would say. Then obviously those two factors are important. If you’re not getting at least seven or three, you better focus in on something about an activity, particularly a home or work activity that couldn’t do before. What they care about is the patient getting better.
Because remember, once they’re stabilized, they have to be on a continua care with flare up. So keep in mind, Acture works well. We need to demonstrate it. Show me on this general index pain scale or function, how much improvement there is. Now this brings me to, for some of you, and I’ve had this question a lot, is being part of the VA worth it?
Does it cost anything to join? No. Do the patients sometimes have some hassles getting authorization? Yes, that’s true. But when you’re paid. Let’s go over it. If you’re getting a standard episode of care for 12 and eight visits, just say the first two 20 visits in a year, considering just the treatment, that’s probably 2000 to $2,500 now, even with taking out exams.
Is that worth it to me? Absolutely. However, am I frustrated with the exam part not being paid? I. But at the same token, that’s not gonna stop me, but this is where if you’re not part of your state and national association, this is where we need to belong. ’cause this is where we need to push back because how are they treating us differently?
Now the downside is they are doing it to chiropractors. To physical therapists as well as massage therapists. So it’s not just you. But at the same token, I think it’s valid to say that it should be covered. ’cause how are you supposed to determine care without an exam because they’re doing this based on a Medicare rule?
Medicare only sets the fees for the va. It’s not the protocol. ’cause if that were true, they shouldn’t pay for acupuncture at all unless it were chronic low back pain. And under supervision, so we know that they’re just choosing and picking certain ones. So I think we’re gonna have a pretty good pushback.
But I do still, it is worth it if you’re thinking, I’m not so sure. We are doing next month in August. A whole seminar on the va, what to do, how to make it work for you, make sure you tune into that. Otherwise, I’m gonna say to everyone, we always wanna be resource. If you’re having issues, reach out to our Connect Acupuncture council.
The next specifically, we highlight updates right on our website. And if you’re a member, it allows you to have direct interaction with me via calls and zooms. And otherwise, until next time to our friend, be well.