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.
Greetings, friends and colleagues. This is Sam Collins, your coding and billing expert for acupuncture. The Profession, acupuncture network of course, and the American Acupuncture Council here to always make sure you have the best and latest information. And one of the things I run into all the time in teaching seminars, but also acting as an expert, is trying to understand what are the differences between certain types of CPT codes.
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The one I want to give an example to is, one that’s come up quite a bit recently is what is the difference between 9 7 1 1 0? 9 7 5 3 0. So let’s go to the slides. Let’s talk about it. What are these two codes? 9, 7 1, 1 0 is exercise, therapeutic exercise 9 7 5 3 0 is therapeutic activities. What is the difference?
How do we understand that? I wanna make sure acupuncturists have a clear understanding, ’cause that certainly can be within scope. Let’s first get into, we have to always make sure we understand the codes well, to choose the right service. Based on the right code, based on the services we’re providing.
So it says here per CPT that select the CPT code of the procedure or service that accurately identifies the procedure or service performed. Do not select a CPT code that merely approximated. So you can’t say it’s like it. Like I had someone that found out that hot packs aren’t payable by almost all insurances and haven’t been for quite some time.
So he said I’m going to bill hot packs. Infrared heat with the idea being, theoretically any warm body. Emits an infrared portion of the heat spectrum to some degree. That’s not really the intent. Certainly infrared heat is a little bit beyond just a hot pack. So again, we want to be careful of trying to twist things.
If it doesn’t fit exactly, make sure you’re using an unlisted code, which pretty much means it’s not gonna be paid, but use the code that best identifies it. Here we have to remember as an acupuncturist. Can you do more than just deliver acupuncture? Of course, your scope of practice often can be very broad, and I will say certainly look at your state.
If I teach in your state, certainly get a hold of me. We can work on that. Understanding what type of services you can do beyond obviously evaluations, but you’ll often see in your scope it’ll say adjunctive services. The adjunctive services often are very broad. It includes a lot of physical medicine services that might include heat, massage, exercise, and so on.
So do verify your scope. But generally all physical medicine services are generally within scope done with the idea of a traditional medicine slant to it. So let’s take a look specifically at two codes here today. 9 7 1 1 0. You’ll notice as a therapeutic procedure, one or more areas 15 minutes, which means it’s face-to-face time, just like acupuncture and therapeutic exercise Says therapeutic exercise is to develop strength and endurance, range of motion and flexibility.
Okay, so the standard things you do, if you told someone to go out and exercise, what would they think they’re going to improve? I think that’s what we’re seeing with that. Pretty generic, Qigong, if you will, but what about a therapeutic activity? Now you’ll notice the one in the bottom, 9, 7, 5, 3 0 says therapeutic activities, direct one-on-one patient contact by the provider.
So that’s still the same, have to be there. But then it says, use of dynamic activities to improve functional performance. Therein is probably the biggest difference. Exercises generically just to increase strength, flexibility. Therapeutic activities are exercises, but specifically done to create a certain or specific functional outcome.
So 9 7 1 1 0 are movements and physical activities designed to restore function and flexibility. Okay, it. It includes instruction and feedback. So realize when you’re doing this face-to-face, it doesn’t necessarily mean that you’re staring at the person touching them, but you’re supervising, making sure they’re doing it properly, safely, maybe assisting them.
But it does require you be one-on-one. You cannot do exercise with two people at the same time. They can be doing that, but it wouldn’t be this code 9 7 1 1 0 is one-on-one. When you’re with a patient, maybe they’re doing yoga poses, maybe they’re doing tai chi or any type of exercise for strength, flexibility, endurance.
In fact, if you think of exercise generically, it fits almost everything we think of when you go to the gym. Bikes and treadmills, gym equipment, weight equipment, isometric, isotonic, isokinetic, but includes passive things like stretching. Might be assisting the person just in stretching.
So certainly any of that fits. Just make sure you’re documenting what exercises I. How much time you’re spending in doing it. So simple things like knee to chest stretching, maybe a low back rotational stretch, anything like that certainly fits. Notice. These are ones that you might be directing the patient to do.
Now this might be one we probably give them to do it more at home later, but certainly when they’re doing this in the office with you, that is absolutely a billable service. Now, what is the difference of 9, 7, 5, 3 0 exercise? I think we can see pretty easy and straightforward, however. 9 7 5 3 0 says one-on-one patient to improve functional performance.
So this involves functional activities, bending, reaching overhead activities with very specific outcomes to increase a function. So let’s say by example, you had a person that is a grocery store clerk and they hurt their wrist. When you strengthen that wrist, is it just to strengthen or is it to strengthen it to have specific tasks to allow them to do their job at the grocery store?
The same exercise that might be for someone just to strengthen the wrist generically, may be the same for the grocery clerk, but because you’re specifically liking to do a specific task, whether it’s going to be reaching in and out of a bag and lifting items, makes it more an activity. So always think of the outcome, realize all exercises.
Could be therapeutic activities. All therapeutic activities potentially could fit under exercise, depends on the why. So here’s the best way to think of it in choosing it. Look at all these pictures on the right. Could you say to me, oh, Sam, that one is exercise. This one’s a therapeutic activity. We cannot tell from the picture because choosing the code depends on the intent of the task.
So follow me here. If you’re doing abdominal curls, they certainly can be used to strengthen weak abdominal muscles and build as exercise. They come in their stomach muscles are weak. We’re doing abdominal curl strength in the stomach. Great. However, what if the patient is performing the abdominal corals specifically because their abdomen is so weak, they don’t have an ability to rise up from a lying down position or get out of a chair because the stomach is too weak.
Now all of a sudden. Those exercises, yes, they’re strengthening the stomach, but it’s there because we need an outcome that it’s there to perform. Getting in and out of a chair or lying down, that’s the activity and that’s why this is worth more. To give an example, 9 7 1 1 0 has a RVU of about 0.89.
Compared to 9 7 1 9 7 5 3 0, which is 1.15. So you’re gonna see that’s almost a 30% difference. It’s worth quite a bit more because this is designed specifically for that patient, something for them to do, not just generic for everyone. If everyone does the same thing, I’m gonna say, ah, that’s probably exercise.
But best practices determine what is the outcome expected from the task. Is it simply just to strengthen? Or is it a functional performance? When it becomes a functional performance, realize the higher value is you’re designing something specific for this patient’s needs. And I think when you think of most exercises, I think that’s what we do.
Now, obviously if everyone gets the same sheet, the same things, okay? But assuming we’re gonna have some nuanced differences, I think it’s far better to look to make sure we’re choosing the right one, because certainly one is worth quite a bit more. And I want you to be paid what you’re worth. Don’t be afraid to code what you’re doing so long as you document it properly, I will always support you.
That’s what we do at the American Acupuncture Council and the network. To differentiate things. Make sure you have the right resources. That’s what our network does. You’ve been to our seminars, but have you ever thought of, Hey, let’s have an expert on task. I could be part of that. Join our network. We’re with you one-on-one, and you get all our seminars free.
Till next time, my friends, I wish you the best.
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When we’re treating the face, we’re treating the entire person because facial acupuncture impacts not just our appearance, but it affects the function of the face, and it also affects a person’s spirit. So when we think about facial. Cosmetic acupuncture, which is what I’m going to talk about first.
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, my name’s Michelle Gellis. I’d like to thank the American Acupuncture Council for an opportunity to present to you today on treating the face as a whole. And this is part one, so you can go ahead and go to the slides.
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So my presentation today is on a multidimensional approach to facial acupuncture. As I mentioned, my name’s Michelle Gellis. I am currently on the doctoral faculty at Ossan University. I’m a formal faculty member and clinic supervisor at the Maryland University of Integrative Health. And I am a published author and regular contributor to the Journal of Chinese Medicine, and I’m a columnist on acupuncture today, and I’ve been teaching facial inter facial acupuncture classes internationally since 2005.
This is the cup of my. Book that has recently been published on Treating the Face. It is a hard cover 15 chapter book on all aspects of treating the face. And you can scan that QR code if you wanna check it out. So when people think of facial acupuncture, the first thing that comes to mind is cosmetic acupuncture.
But treating the face is much more than just cosmetic. When we’re treating the face, we’re treating the entire person because facial acupuncture impacts not just our appearance, but it affects the function of the face, and it also affects a person’s spirit. So when we think about facial. Cosmetic acupuncture, which is what I’m going to talk about first.
That works with both the body and the face, bringing blood and cheese circulation up to targeted areas in the face. It stimulates collagen and elast in production, improves the tone of the skin and the of the skin. It enhances circulation and reduces inflammation. So puffiness and increases the natural glow of the face.
So you look rested. You have more color in your cheeks. And additionally, because of the. Nature of the acupuncture points on the face, you are supporting your patients’ overall health, their digestion, their immunity, and their overall circulation. Facial acupuncture can erase five to 15 years off of the face, and it’s great for lifting and treating on a very deep level.
The important thing when you are performing facial acupuncture is to use precision needling techniques, which typically involves training with someone who’s very well experienced, who’s been doing facial acupuncture and teaching facial acupuncture for many years. So how does cosmetic acupuncture work?
Cosmetic acupuncture brings blood flow and oxygen up to the face and it brings nutrients to the skin cells so your skin will look better. It does take about 28 days for collagen to regenerate, and that is increased if someone is older. So you really do have to do a series of treatments. It’s not just a one and done.
And once a person has gone through a series of approximately 12 weekly treatments, then usually they can start to spread their treatments out over time and eventually come once a month or just seasonally for touchups. Cosmetic acupuncture also utilizes motorpoint stimulation, and this can help with the functioning of the muscles in the face, and it will therefore balance.
Overactive muscles. Muscles that are too tight, causing the skin to contract or weak muscles, which can cause the skin to sag. It can help to enhance the jawline, giving a more lifted and supported appearance. And it also helps with the mid-face support. And this all happens through proper engagement of the facial muscles.
So if we just look at the layers of the face, we have the skin, then there’s some superficial fat, and then this mass layer. The superficial muscular AP neurotics, AP neurotic system, which is very unique to the face. We have some retaining ligaments, deeper fat on the lower part of the face, and then we have some deeper fascia and the bones and this mass layer.
Is what enables us to make our expressions because the muscles on the face are connected directly out to the skin. So as we can see, we have bone muscle. And skin. And so what happens is as the muscle contracts, the skin moves, and over time when we’re contracting these muscles, either through smiling or frowning, the skin that’s over the muscle will contract and it will eventually form lines and wrinkles and folds.
So here is someone who doesn’t have a lot of signs of aging, someone who’s a little younger. Then as we get older into our fifties, we can begin to see some signs of aging. And then as someone is progressively older, they’ll start to get forehead lines, bolts and more wrinkles.
In addition to wrinkles from facial expressions, gravity can cause the neck to hang down and jowling, especially around the mouth area and the skin on the cheeks and underneath the neck. The platysma bands start to form the cheeks start to sag.
And different facial expressions related to our emotions will cause different sorts of wrinkles. For example, smiling can cause crow’s feet frowning or being angry can cause these lines in between the eyebrows and cursing the lips a lot. If you were pensive, that’s an expression can cause lip lines.
The forehead is a kind of a zone of anger and frustration. The crow’s feet area, smiling. Sometimes sadness, depending the lips from overuse or estrogen loss can lose their. Plumpness and cause wrinkling the chin, if there’s a lot of fear, the chin can pucker and then jowling and the neck area frequently is a sign of cheat deficiency.
So we have emotions that can cause wrinkles cheap. Blood and body fluid are also related to the skin and how the skin looks. If the chi is deficient, you can get a withered looking appearance. If the chi is stagnant, it can block the flow of blood and fluids. So blood causing discoloration and fluids and cause puffiness, especially under the eye area.
So let’s take the liver, for example. If we’re looking at the liver system, we can see that stagnant liver blood can cause liver spots and liver blood deficiency can cause the skin to be dry. And liver cheese stagnation can sometimes manifest as anger and frustration, and this can show up in between the eyes.
So there’s a lot of different ways with our medicine to treat the emotions. A five element. Treatment. If you’re trained in five element, acupuncture can help to balance the organ systems and the emotions. Additionally, using the entry exit points on the face can be very beneficial for opening the face up, getting a smooth flow of Qi between the face and the body, between the Z and the.
Also allowing for a balancing between the organs, facial motor points can be very beneficial for treating the face, especially expression lines. And there are many muscles on the face and neck, as you can see. Some of them are listed here. This is not. A comprehensive list, but this is these are the muscles that we frequently use motor points for when we’re looking to treat some of the emotional manifestations.
Some of the, of some of the expressions. So here for example, we have the expression of anger. So here we have a relaxed face, and here we have an angry face, and you can see how the muscles get contracted. And by using the motor points or the different muscles, which are the motor points are located. The most electrically acceptable part of the muscle.
So you treat the motor point and it treats the muscle and it allows the muscle to get back into normal functioning. And this can help with not only the manifestation, the external manifestation of the emotion, but it can treat the muscle, it can treat the acupuncture point. Which helps to treat the whole person.
Many motor points on the face are acupuncture points.
This is actually an image from my book. This is from a chapter called The Anatomy of Expression. And it’s a little easier to see here. Side by side, a person making the expression, and then a split view of a relaxed face with the motor points and then the contracted muscles on the right.
Facial Gus Sha can be very beneficial for treating the skin, helping to work with fascial adhesions and tension in the face can help to sculpt the face. It’s very relaxing to the patient. It’s very calming to the spirit. I really love Jade Guha tools. I find that they tonify the skin and they help to nourish the blood.
Facial cupping is also a wonderful technique. These small glass facial cups. That are easy to squeeze, are wonderful for treating the face. And of course, when you’re doing facial cupping or facial gua, you never wanna leave any marks on the face. So if you’re going to do either one of these techniques, protocols, please get properly trained.
And everything that’s happened to us in our life gets etched on our face. Our fla, our face reflects our life story and needling the face helps to release stored trauma and can really transform the she on a very skin level. Related to what we do, but in no way a deep level or a spiritual level treatment microneedling using a device like this, a microneedle pen with microneedle cartridges. This can treat very skin level conditions on the face and on the body chest. Back and other parts of the body as well.
And here’s an example of microneedling. You can see on a very skin level, some wrinkles around the mouth. And then after a few treatments the wrinkles are gone. So if you’re interested in learning more about facial acupuncture. There’s a QR code there for my website, facial acupuncture classes.com, and you can find me on Facebook into Instagram, LinkedIn, and TikTok.
Under my name, Michelle Gellis and I have a Facebook group called Facial Acupuncture. Thank you so much.
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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 everybody. This is Perry Barnhill with the Fearless Acupuncturist. Today we are gonna talk about OIG and an exclusion list and what it means to you and why you need to be aware of it. Wanna give a big thanks to the American Acupuncture Council? Go to slideshow please.
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Okay, here we go. Understanding and using the OIG exclusion list. This is about performing certain exclusion checks. On your staff regarding the Office of Inspector General. Let’s talk about that. This is something that we want to check every single month. Now put it in perspective here for you.
We got Health and Human Services at the top, HHS, you’ve heard of that. And then we have OIG, the Office of Inspector General. Now they’re very closely related to the OCR, which is the Office of Civil Rights, and this is where all the HIPAA stuff comes in. These two are basically sisters to each other, and they’re so important that you need to be aware of.
That’s why we’re talking about this right now. What is the OIG exclusion list and why do we need to check it? Okay, so here’s what it is. The exclusion list is a list of individuals that the government collects that basically shouldn’t be employed in your office. If you’re accepting any federally funded programs such as Medicare, for example, or even if you’re in some acupuncture networks for P-P-O-H-M-O or insurance networks.
Now, if they’re on this list. Is something we need to be aware because we may not keep them employed. This is something we want to ensure compliance with Medicare, Medicaid, like I said, certain contract requirements by regularly verifying employees. Who do we need to check? Okay, now everybody that we need to check is pretty much anybody in our office that’s involved in any kind of patient care or has any kind of access to protected health information.
So you got your staff that’s involved with your patient care. Any employees handling any kind of billing procedures or protocols, personnel. Anybody who has access to protective health information, I’m not talking about a janitorial service or a cleaning service. Those folks though, if you don’t know already, they need or you need to have them fill out certain forms such as non-disclosure statements and agreements.
Because even janitors that come into our office may accidentally see protected health information. And that’s something just on a side note that you need to be aware of and you should have protected and you should be speaking to them about. The Medicare exclusion list. This is a list of an OIG website that I want you all to go to.
Here it is exclusion dotig.hhs.gov. You need to go here, and this is where you need to start doing some check-in. Go in there and enter your employee’s last name and first name, and if you need to, because some people have similar names or same names, use additional details such as their date of birth. If you have other providers in the office, you need to check on them as well to narrow the results.
So how do we interpret these results if their name actually pops up? The good news is if it doesn’t pop up, they’re good to go. You don’t need to worry about it, but if one of your employees or your personnel’s name pop up, make sure you click to verify and redo, review additional details again to make sure it’s not the same person that you have in your office.
So you can enter date of birth NPI numbers if they’re providers for confirmation. And believe it or not, there’s another exclusion list that I want you to check. Even though I’m talking about this and there seems like it’s overwhelming, at least a little bit. It’s easy. It’s very fast. You literally go to those websites, you check in their names.
It pops up very fast, and their name’s either on there or it’s not on there. I. The other one is the SAM exclusion list. This is the next website you want to go to and just double check and make sure nobody in your office is on this list. sam.gov. Just go there. Check how to search is very similar.
You use the entity verification search function and again, you enter the information of the employee’s name or any personnel that you have in your office to make sure they’re not on that list. Some verification tips. Provide as much identifying information as possible. Again, to make sure maybe you got two people with the same name, confirm the details and make sure that they match.
The last thing I want y’all to check is your state-based exclusion checklist. So we got the government, we got the SAM list and then also double check any kind of exclusion list. And again, just to reiterate this, if you accepting any federally funded programs, you have to make sure that none of your employees or anybody in your office is on this list or even other providers.
’cause if they’re on this list and you hire them and they’re employed and they find out. You can get in some big trouble and the fines are pretty steep. So again, where to check for state specific list? Use your state specific portal. Alrighty, and make sure that they’re not on that list as well. How to search?
Very similar. Locate the sections for OAG provider sanctions and you enter your employee’s name and other identifying details if needed and if possible, reviewing the information. Check details again to ensure that it matches the individual. Again, making sure it’s not the person in your office. Maybe they got a same name, and I know I said that a thousand times, but just double check.
Note any active sanctions or exclusions relative to state Medicaid programs. Here’s some best practices for verification. Always verify with multiple data points for the reasons we’ve just talked about. Cross-reference your results. Check the OIG, the Sam and State Base to confirm accuracy and just as important, make sure you document everything as if it’s not documented, they will say, you never ever did it. So make sure you do that and make sure you do it monthly. The importance of regular exclusion lists, compliance meets Medicare, Medicaid, and also many insurance contracts. You have to make sure they’re on this list. Risk management helps prevent potential fraud and abuse.
’cause if those folks are on this list, it’s likely they have some kind, they’ve been convicted of some kind of criminal action, and there’s something going on that you definitely may not want them in your office. All right? Quality insurance ensures that other qualified personnel have access to sensitive patient care and information.
So you gotta be safe there. You gotta protect that information. So here’s some next steps. Just to recap, use OIG website and Medicare exclusion list checks to make sure they’re not on the list. The SAM exclusion list. And also check your state. Record this in your manual. Make sure you record it in your manual.
’cause again, like I said, if it’s not checked, it’s not done and you need to do it monthly. It doesn’t take long. So just make sure you get in there and you get that done. Additional resources, I’ve went over these, but here’s a screen just to check again, different spots you can check. If you don’t know if you’re HIPAA compliant, the likelihood is that you’re probably not.
Many providers may have a form or two in the office, and they think that means that they’re HIPAA compliant. So this is why we came up with the checklist here. Go over this checklist. Look at the boxes here. If you’re not checking every box, the likelihood is very high. Likelihood is that you’re not HIPAA compliant.
Make sure you do so because the fines associated with any HIPAA noncompliance are very scary. You can scan the QR code as well. If you want to schedule a demo, you can go to fearless provider.com right here as you see, and we can go over a demo with you, show you how the program looks, what exactly it looks like on the inside, how to navigate it, how to have your staff navigate if you choose not to.
If you wanna just get started, you can go to fearless acupuncturist.com. You can get started that way as well. If you want to contact me. If you wanna reach out to me ’cause you have questions or concerns or anything like that, please feel free to do i’m more than happy to jump on the phone and jump on the site, go over a demo with you and answer any questions that you may have.
You can contact me at Dr. perry@betterhipaablueprint.com. Also, you can scan the QR code here as well. If you got questions, reach out to me please. I am more than happy to help any and all of you. In the meantime, everybody, have an amazing day and we will talk to you soon.
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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.
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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 friends, it’s Sam Collins, your coding and billing expert for acupuncture. You of course, as the profession, the American Acupuncture Council, the network, all of that. We’re here to always support you and help you. And one of the things we’ve had some issues coming up is what about audits? Now that many of you are billing more, you might think, uhoh, I’m gonna be audited.
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First thing I’ll tell you is generally you’re not gonna be audited. Very few offices get audited, but we want to talk about when you do what to be prepared for, what do you wanna do preemptively? I don’t want to be reactive, let’s be proactive. So let’s talk about what to do. And particularly if you’re insured with the American Acupuncture Council, they’re really gonna help you.
So let’s go to the slides. Let’s talk about what do you do if you are audited? You’re gonna get that dreaded letter, you’re gonna get it and you’re gonna feel this overwhelming sense of dread. The first thing I’ll tell you, do not panic. You are a good provider. [00:01:00] You’re there offering your best practice of services.
You’re being helpful. Realize that as soon as someone audits you, I’m also upset like, how dare you think? Because what are they looking for in an audit? You often think of, oh, did I do something wrong? You’ve done nothing wrong. Not at all. It just means maybe they wanna look. Sometimes it’s you’re just lucky or unlucky.
’cause they’re gonna look, there’s a certain amount of government oversight that requires that to make sure that services that are being paid are provided. So do not panic. Read it carefully. The requests, what are they looking for? What type of claim is it? Is it personal injury? Is it insurance? Just what type of claim?
That can tell you a little bit, but also take a look at what data they’re requesting. Sometimes they’re just looking at data to make sure that the services were provided. Think of it, if you’ve never dealt with a VA patient in a weird way, they audit everything you do because they require you send chart notes.
You know what they’re looking for in the chart notes. Honestly, just making sure you did the services. They’re not there looking at the necessity as much as people think they’re looking to make sure, did you do [00:02:00] them and is there a decent outcome? Think of what patient or patients they’re looking for.
Often you might just get a one-off that’s just verifying something. If you get several, that could be a little bit more that they’re looking at, but at nothing I would be overly nervous about. Make sure if you’re a network member with me, get in contact with me when you get this. Let’s review it. Let me audit first often.
You’re gonna be just fine. In fact, I’m gonna say nine outta 10 times for most of you. So think of what are they gonna look for when they’re audit? Just your records. So it is important that you document the services you’ve done. Remember, that’s what notes are there for, to tell that story of the patient.
What do they come in with? How did we help them? What did we do? And what was the outcome? So verify. Basically, if what I billed for is on the claim. If you bill for three sets of acupuncture, I hope there’s three sets in there. You build for a therapy or ENM. That’s all it is. In other words, just make sure the services are there.
So when you feel audit, don’t panic, if you get audited by the IRS. You know what I say? Big deal. Did you lie on your tax form? Did you claim something you [00:03:00] didn’t have? Did you not claim income? If they were to come to me and say, Hey Sam, it looks like you donated money, a certain amount of money to the church.
I sure did. Here’s my receipt. I have no panic whatsoever, but I wanna talk about what things can set you up so you can start to be. A little bit preemptive, or at least be aware what is gonna get. One thing that will definitely get you looked at more than others if you bill high level e and m codes.
Now as an acupuncturist, is it appropriate to bill a high level e and m codes? In some instances, it absolutely is. Think of a patient coming in, maybe they’re post-surgical, maybe they’ve got a lot of issues, might that history be a little bit longer? So therefore, these codes can be based on time. So therefore, if you’re using a 2 0 4.
2 0 5, you better document. How much time did I spend the why? Or is it something that’s severe? I’m not panic about it, just make sure it’s done. Now, here’s one area that definitely can, acupuncturist can run into problems. You cannot bill an e and m code daily. And I’ve had offices that billing and go Sam, I’ve been billing it, they’ve been paying it.
I’m like, I know, [00:04:00] but someone’s eventually gonna look and go, wait a minute, this is every day. Remember, the acupuncture code does include. A small e and m code, A little. How are you doing today? So there’s an embedded exam as part of the acupuncture. This is part of the reason we put modifier 25. Modifier 25 is that indication.
It’s above and beyond. Now realize it’s gonna happen sometimes. What if a person comes on Monday with headaches and then comes on Friday with low back pain? I think it’s appropriate for another exam on Friday because that’s different from the headache. But is that common? No. Most often you’re not gonna see them that frequently.
The other is billing more than four services. Now I do think it’s fairly routine for an acupuncturist to do two, maybe even three sets of acupuncture pretty routinely, which means nothing wrong with that. I think that’s reasonable. But think of therapies a the OR two after. Sure. But what if you’re billing like four additional units of therapies?
That’s like a three or $400 visit. That’s pretty expensive. So I think probably not to say never, but realize that might get [00:05:00] you looked at. ’cause they’re gonna just make sure hey, if you’re billing for that many, did you do them? And then of course, just care. That’s long term. Now keep in mind, medical necessity is the least audited factor when it comes to most services delivered by an acupuncturist.
It really is. I’m not panicked about that as much as people think I’m more panicked to make sure were the services delivered. So again, long-term care or extended care for non-complicated, eh, if it’s a flare up, I’m not gonna be as much of an issue there. Just make sure that it’s reasonable. Okay? But here’s one area.
What if a patient makes a complaint? What if you have an ex staff that’s disgruntled because you fired them? Realize, never compromise yourself with a patient or a staff. Make sure everything’s above board, because now if you have not, it puts you in a vulnerable PO position because you’re knowingly doing something not right.
So don’t give that power away. Make sure everything you do there, if someone makes a complaint. So be it. They can complain. Doesn’t make it right, it just [00:06:00] means they weren’t happy. Okay, so here’s something, take an example. Here’s an Anthem policy that says, now just go to the where it says, as part of our own comp on ongoing claims data, we previously contact you regarding your use of acupuncture services.
And they talk about the letter and it says you indicate, you know that you continue to bill outside the expected ranges. This office is billing three sets every time. Is that necessarily outside of the expected ranges? Maybe slightly. I’m never gonna say, don’t do what you think is necessary, because take a look at the second paragraph in the red, it says, we recognize that many factors may impact the coding of acupuncture services.
In other words, they’re letting you know, okay, you’re billing above. Do you have a reasoning why it cannot be? That’s my style. If someone has a hangnail, okay, I would expect not as many sets of acupuncture compared to severe low back pain. So long as you’ve got that in mind, I think you’re perfectly fine.
I have no issue. For me, it’s always about document what’s there. Because by [00:07:00] example, UnitedHealthcare does this quite a bit where they come back and you’ll see here the coding of the acupuncture code 9 7 8 1 3 and 9 7 8 1 4 both indicate not supported. The medical records do not support. 9 7 8 1 3 was performed.
The documentation submitted does not indicate the time spent with personal one-on-one contact, so you’re gonna notice they’re telling you exactly why the time spent and they say it with each code. So what does it mean? I bet the notes are pretty good. In fact, I know they were, but they didn’t indicate time because notice 9 9 2 1 3, they paid that because what does it say?
It’s supported. They also paid the infrared heat because they indicate it where they did it and the severity of the exam. What I will tell you the big issue for most acupuncturists, please make sure you understand. You must document time, face-to-face for each set of acupuncture. Do make sure for audit protection of yourself, where the services reasonable necessary.
I think that’s always gonna be true. But more importantly, does the e and m [00:08:00] code match? And of course, face-to-face time and points must be there. That’s probably the biggest fault I have. Part of that is ’cause I teach at a lot of schools, frankly, and the schools still sometimes fight back on that. Time is not that important.
I don’t care what we think. It’s what the rule says. Please put time. And of course, if you’re doing therapies and you should to some extent, the what, why, and where you did it I think are important to do. And of course, make sure there’s outcome. Here’s the good news. You know why medical necessity often is never an issue for acupuncture because your pain management, and so long as you’re showing you’re making the patient improve or dealing with flareups pretty much a non-issue.
I can tell you if your notes are just average. Not great, but not terrible, but not great if you show a good outcome. Those are great notes. Here’s why. What is an insurance? What is a patient paying you to do? Make them better. Demonstrate that’s always gonna put you in the right position. Good documentation.
Practice helps ensure that your patients receive appropriate care, okay? And from any other provider can [00:09:00] rely on your records to know what was done. Bottom line is. A couple of things to be careful. Remember inducements and kickbacks, that’s where you get issues from your patients. Make sure if you write off their deductible.
That may be helpful to them, but if they’re mad at you, could they turn you into their insurance company for an inducement? They could. So don’t leave yourself vulnerable. If it’s a hardship, make it a hardship. And do remember incident two and supervision of staff? For the most part, acupuncturists do not have an ability to supervise an unlicensed staff person.
Meaning you cannot have just a massage therapist doing something under your license. There’s a few states that do Massachusetts and part in Arizona come to mind, but most states, whatever you do and bill for, you’ve gotta do unless you have another licensed acupuncturist. So be mindful you cannot have someone else do services that also is not an acupuncturist.
Bottom line, keep it simple. Ackman’s razor. Simple answer. A provider can read your notes and identify the service. If you told me I spent 22 minutes face-to-face and I inserted needles into, UB 34 and heart [00:10:00] seven. That would be adequate. Now, you might think, Sam, that can’t possibly take 22 minutes.
It’s not just about the time of insertion. Remember, as soon as you go in the room with a patient and say, hi, Mr. Jones, how are you feeling today? The time of acupuncture starts. So it’s all that stuff that you do leading up to the insertion plus the insertions, plus the removal, plus the counseling is all there.
So that’s what we’re documenting. But the other thing I want you to keep in mind though is what if you get an audit and you’re a little panicky? I don’t know. I’m scared in this way. Don’t be scared, particularly if you have coverage through the American Acupuncture Council. I wanna highlight to many of you, and I’m not sure why many of you don’t just use this one ’cause it’s simple and straightforward, has great coverage.
And you’ll notice here I put the arrows, you have covered proceedings up to $30,000 or 50, depending board defense, audit, defense. They’re not gonna pay the fine, if you will. If you get that, you know what they’re gonna do. Pay for your defense. I can tell you in my experience in dealing with these. We win [00:11:00] 90% of the time because often they’re looking at something, they’re like, oh, wait a minute.
Let’s look at it with another set of eyes. Make sure you’ve got yourself in place to be protected. I’m gonna tell you, the American Acupuncture Council, myself as the network provider is here to support you. We want you to deliver good services. In fact, if you’re not practicing. We don’t have a business.
We are here to support you. We wanna make sure you’re doing the optimum to make your practice successful, which means I work on the money side. If you want to help to learn how to make more money, take a look at the network service with me and I’ll guarantee you’ll be doing better. Until next time, my [00:12:00] [00:13:00] friends.
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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.
Hello everyone, and welcome. I’m Dr. Krystal Lynn Couture. The pelvic acu. And before we get started, I wanna say a special thank you to the American Acupuncture Council for hosting this vlog. If you haven’t been to the American Acupuncture Council website, you absolutely should go there because there are amazing vlogs like this one that are filled with little nuggets of gold for acupuncturists and.
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They do a really nice job of sharing those teachings in little bite-size bits. So let’s get started with today’s workshop. We are going to be talking about postpartum and the pelvic floor. I. So what’s inside our workshop today? We’re going to be talking a little bit about sitting the moon or sitting the month.
We’re gonna talk a bit about miscarriage and abortion. We’re also going to have a chat about some postpartum challenges that moms could encounter. We’ll talk about the healing process that one goes through. Through the postpartum process. We’ll talk a bit about the hormones, we’ll talk about the perineum, and we’ll talk about uterine involution.
So here we go. Alright. Sitting the moon or sitting the month, lots of cultural traditions, including Chinese tradition around the globe, suggests that the mom and the baby really spend the month or the moon. Being protected, being nurtured, being nourished, bonding, and recovering with each other. That means there’s very little demand.
On the mom and on the baby, except for healing and coming together in harmony with each other and the outside environment, right? Western tradition suggests that recovery period postpartum after childbirth, there’s an acute period of 24 hours, a subacute period of 24 hours to six weeks, and then a delayed recovery period, which is six weeks to six.
Months. And so there’s a difference in how Western terminology and how Eastern terminology looks at the postpartum recovery period, and what is encompassed within that. So let’s get into sitting the moon. The traditional recommendations are lots and lots of rest for the mom, and this is really bed rest including 10 hours or more of sleep per night.
The body has just been through an immense transformation and a major outsourcing of. Energy or expression of energy, right? So rest and sleep are really important. During that first month, it brings in the support of family members, friends and nurses to maintain the cooking, the cleaning, and other household tasks.
It’s really not part of traditional culture that these things are done by the mom while she has the new baby at home. Another part of sitting the moon that is done in traditional cultures is abdominal binding, and that’s really to help reduce the laxity in the abdomen and restore the proper pressure.
Within the abdominal cavity. And we’ve talked a little bit about pressure within some of our workshops here, right? So the abdominal pressure directly impacts the pelvic floor pressure. Now you can imagine after the birth process that the pressure change is going to be pretty significant.
Abdominal binding helps to bring that pet pressure. Back to a normalized state, and it’s also going to help with the pelvic floor healing as well. And of course, eating and nourishment are going to be such a big part of this sitting the moon period. And also of course, for milk production, right?
We wanna make sure that moms are getting the right nutrition into their body. That’s going to be satisfying, that’s going to be nourishing, that’s going to fill the coffers with what might have been depleted. During the pregnancy and then during the birth. But of course, it’s also important to remember that balance, right?
So not eating too excess is another important facet to the postpartum dietary kind of idea. Okay. And then of course, maintaining warmth in the body, right? As Chinese medicine practitioners, it’s very rare that we recommend cold. We tend to go toward warmth. Warmth is particularly important for new moms postpartum.
It continues to help to support the movement and the consolidation. Of the qi, right? So again, it’s that harmonization. What is too much, what is not enough? Let’s balance that out and the right types of warmth are going to be supportive in that way. Okay, let’s talk about some of the traditional restrictions that are going to be part of sitting the moon in Chinese culture.
And these would include washing one’s hair. We know that is a restriction as well during menstruation. It continues, of course, into postpartum. Bathing avoiding a draft is gonna be really important. Lifting, especially lifting the baby. And in traditional cultures, actually even, so I’m Italian and looking back into Italian culture, this is also a, a philosophy there as well. So it goes across the sort of folklore and the tradition of medicines around the globe. So lifting the baby, all that weight can help and support the mom’s poor posture, right? So we have this laxity in. The body after the birth, right? So the abdominal muscles are stretched and they’re weak, and generally there’s this forward tilt of the pelvis, which means the back muscles are tightened and those glute muscles are stretched.
So there’s this imbalance, and until that balance is restored within the body, whenever the mom is doing lifting, she’s facilitating. More of that poor posture. So lifting whenever possible is something that should be done by the nurse, by the family members, by community. And I think that’s the biggest key when we’re talking about sitting the moon and cultural tradition, is that community is such a big part of these traditions.
Where in Western society it’s almost mom’s gotta do so much. By herself and if she’s lucky, dad gets, a period of postpartum time as well. So dad can help a little bit, but it’s really leaning into community is so helpful. So as acupuncturist, if we can provide our clients with resources for accessing community for our postpartum moms, that’s such an amazing asset.
Okay. Another thing, climbing stairs, again that contributes to poor posture and also too much load on the body and change in the abdominal pressure. Nursing in sideline position is so important. Any watching TV reading or. Now we say scrolling as well. This is all going to be things that take the mom’s energy or put in energy that is going to impact what she is sharing with the baby, right?
And also shedding tears. And of course, we all know the Chinese proverb that says one teardrop from a postpartum women is worth 500 kilograms of gold. So just keep that in the back of your mind and share that with your clients. Let’s talk about miscarriage for a moment. Miscarriage is considered to be more serious than childbirth, according to Giovanni Macha.
And this is also true in a lot of the traditions, right? So women who’ve had a miscarriage or in abortion for that matter, the postpartum cycle could actually be extended. And the reason for this is because the natural cycle of pregnancy. Is interrupted, it is changed. The body has an expectation to complete a cycle when it is not going to complete that cycle.
That is a huge interruption in the cycle, in the energy of the cycle, and of course within the hormones. So not having completed the cycle can create quite a struggle within the body, mind, and spirit. Let’s look at some statistics here. Postpartum complications from a 2024 study actually showed that 35% of women experience pain with sex.
32% experience, low back pain, 31% experience urinary incontinence, 34% anxiety. 19% experience rectal incontinence, 15% experience pain I’m sorry, fear of childbirth. 11% peroneal pain, specifically 11% secondary infertility. Prolapse is 1.4 to 13.7%. So those numbers were a little bit varied depending on where the study was looking.
And then that’s with a vaginal delivery with a c-section. The prolapse is were 2.4 to 21.2%. So there’s a lot of variation there and that’s something I think that needs a little bit more research. But as you can see, there are pretty big. Statistical indications that show that there are a lot of postpartum complications.
And as acupuncturists, guess what? There are a lot of ways that we can support our clients, especially if we specialize in pelvic care, postpartum depression as a complication. I gave this its own slide, so in 2009. 2010, there was 9.4% of women reporting postpartum depression. In 2021, that number jumped by 104% to 19.3% of women.
Now, of course, during this time, there was the covid, so that was part of it. Also, women are talking more about what’s happening in their bodies, right? Women are starting to be more and more aware of what’s happening. This increase was noted across all races and ethnicities. There was also a substantial correlation between postpartum depression and obesity.
So these are all important things for us to be aware of with our clients. Okay, so I’ve included this chart for you to have a look at. You can go ahead and pause here if you like, to look at this interplay between the intrinsic and extr extrinsic predispositions to pregnancy, labor and childbirth, and medium term and long term maternal complications.
And you can see that these go out long after childbirth that we can still be seeing. Complications, which include prolapses and that sort of thing. So what does it take postpartum to heal, particularly to heal the pelvic floor? I shared a little bit of this slide in our pregnancy workshop, but we’re gonna go into more detail here.
First off is organ alignment and function. If you watch my pregnancy presentation, you know there are major changes within the organ systems in the body during pregnancy, which means that the body kingdom. Is out of order. There was a renovation that happened within the Body Kingdom, and that’s okay.
That’s not a bad thing, but balance needs to be restored. We need to help moms to find proper alignment and of course, utilizing the meridians. Is going to help those organs to come back into balance within the whole of the body kingdom. Now, the uterus size and position, we’re gonna talk about this more.
There are major changes that occur with the uterus size and position. It needs to expand, it needs to move up in the abdomen during the pregnancy, and now. We want the uterus to go back to size. I talked a little bit about ab abdominal binding as a strategy. That’s one way for sure, but there are also other ways that the body can naturally support itself in the uterus responding.
To its natural size and position. Then there’s the perineum that requires healing. There’s the ligamentous and joint recoil and positioning. All those ligaments in the sacrum and the hips and the back have stretched out. Why? They needed to support a baby and then they needed to push a baby through, right?
So we needed space for that. So that recoil. Needs to happen. The fascia, the diaphragms, and the postural alignment, there is going to be a whole new systematic alignment of the body that’s going to occur postpartum. I. Now if moms are not in a state where they’re able to take care of themselves, it’s really hard for that ligamentous recoil and those fascia and diaphragms to align and the posture to be appropriate for our clients through the postpartum phase.
And then, as it’s harder and harder to get it back as time goes on, right? What we have to put in is a lot more. The muscles of the abdominal the abdominal wall, the back, and of course the hips and the pelvic floor, they all went through changes as well. They were all stretched or tightened, so they need to return to some sort of harmony.
Okay. Blood and fluid leveling. We know about bloods and fluids in Chinese medicine. This is a big part of what we do. There’s a lot more fluid in the body when one is pregnant and then there’s a change in that fluid, so that’s going to be a pressure equalization once again, that occurs and it needs to be right.
For where the body is and what the body is going through. For example, a mom that’s nursing is still going to have an increase in fluids, different fluids, different energy, but they’re still going to have that increase. So we’re looking for the harmonization of where they’re at that moment. And then we’re looking at the energetic flow and the meridian flow, and then we’re looking at emotional harmony, right?
So there are a lot of things going on with postpartum moms. We talked about hormones in just about every one of our workshops here. We’re gonna talk about ’em one more time so we can see that at birth we have an increase in progesterone, estradiol, and cortisol. Those and those are all going and placental tigen.
So those are all going to increase. They’re gonna spike at the gradually increase and then peak at. Birth, and then they drop right off. That is a major change. Then we see oxytocin and prolactin come in and they have these peaks and valleys. These peaks and valleys are going to be impacting what is happening in the mom’s body and how her healing process is going to occur.
So when do hormones return to normal after childbirth? Okay. The common response is that, you’ll hear from your western doc is within six months, hormones return to pre-pregnancy levels. Period. Done. Okay, great. In theory except there is very little evidence-based research on postpartum hormones.
In a timeline form, there is research on postpartum depression being linked to decreased progesterone and decreased estrogen. There are studies beginning to emerge that show women who give birth at an older age may have different hormone responses. So basically what we’re saying here is there’s a lot of questions.
Each body is different, and I think when we’re able to transparently answer that question with our clients so that we’re not setting them up for an expectation that may not be reality, I think that’s when we’re going to be able to come in. With our compassion, with our knowledge, with our awareness, and really support them through the process and say, each experience is individual.
Your experience is your own experience, and here’s what we’re gonna do to help you in your process based on what in your clinic. Okay, so estrogen muscles. Let’s talk about the healing process. What we know is estrogen preserves muscle mass. It supports muscle repair. It helps muscles to generate force.
It increases collagen content. It plays a role in muscle metabolism, and it presents muscles against apoptosis. Okay, what we see, remember that gradual increase of estrogen and then that estrogen drops off after the birth right? So we are going to be in a diminished state of estrogen while the body is trying to recover those muscles.
The sudden decrease in estrogen can create decreases in muscle suppleness, strength, power, recruitment, and function. Of those pelvic floor muscles, and of course the abdominal muscles, the back muscles, all the muscles of the body are going to be impacted. But the pelvic floor in particular, because that is where the baby had to find its way through, now talking about progesterone, what we know about progesterone, it supports muscle relaxation. It supports protein synthesis within the muscles, and it maintains connective tissue elasticity. And what happened to progesterone? Same thing. We had that gradually increase and then a drop off. The sudden.
Decrease in progesterone can contribute to muscle weakness, proprioceptive confusion, and stiffness within the tissues, right? So we’re really at a disadvantage. The body is at a disadvantage to naturally recover on its own with zero intervention. Zero thought about the pelvic floor, zero thought about the abdomen.
The perineum tears occur in 80 to 90% of first time moms. A first degree tear is just the skin being impacted. Second degree impacts the skin and the muscle. Third degree is going to be a tear that includes the skin, the muscle, and it’s a partial tear of the external anal sphincter. Fourth degree includes the skin, the muscle, and is a complete tear of that external anal sphincter.
Now an episiotomy is when they do a surgical cut to try to control the the tear or to expedite the birth sometimes they’re done in emergency situations, sometimes they’re done to prevent serious tearing. The research on whether or not an episiotomy actually can prevent. Serious tearing is questionable at this point.
There is not good evidence to show that. That’s a topic for your client to have conversation with their midwife or their OB about. The stretching and expansion of the perineum is a natural process. The perineum will start to expand at the end of the pregnancy. That’s a good thing.
We want the perineum to expand. That’s going to help the process. Two to eight weeks after the birth, depending on the stretch and the tear. Intensity. The perineum generally starts to return to its pre-pregnancy state, to its unstretched state, and of course that varies significantly based on whether or not there is tearing.
There is some evidence that’s coming out, that perineal massage, that breath work, that relaxation can all really help with reducing the risk of perineal tearing. Now of course if the perineum does tear, that’s another implication, right? For what we have to do to address the pelvic floor. Okay, let’s talk about uterus, involution really quickly.
Okay, so this is the womb. Returning to its pre-pregnancy shape and size, involution begins as soon as the placenta is delivered. So basically the body just doesn’t get a rest. It does not get a rest. It goes through this pregnancy phase, which is a lot. It goes through the birth, which is an extreme amount of energy, and then the placenta is delivered, and then the body is oh, okay.
Now we start. Now we start again. So it’s the next part of the process. It’s that return as the uterus contracts to deliver the placenta and subsequently continues contracting, right? It starts to decrease in size. That contraction with nothing there to hold the shape kind of makes it start to shrinking.
Process. Involution, they say, takes about six weeks total. With more oxytocin in the body from breastfeeding, they say that the involution actually takes a little bit less time. Signs of involution include the Lok qia discharge, and of course postpartum cramping and contraction. Now pelvic floor muscle recovery postpartum.
A 2022 study found that at 12 months postpartum falling of vaginal delivery. The pelvic floor muscles are not yet fully recovered compared with their mid pregnancy values. Okay, so that’s not even talking about their pre-pregnancy values, that’s talking about mid-pregnancy values. This number should be concerning to you as a healthcare provider.
Some contributing factors that we see here are going to be a vaginal delivery, of course, versus a c-section tearing or episiotomy the size of the baby, difficulty of the delivery. What we know about the pelvic floor muscles is that it takes six to 12 weeks to build muscle. Muscles do not build themselves, so that means that it takes effort working with the pelvic floor to restore harmony.
And to restore balance. So where do we come in as acupuncturists? As acupuncturists, we have some amazing tools within our toolkit that can really support clients. And these tools are of course going to include using TCM. To help rebalance the patterns in the body and restore and nourish the system.
We, of course, have herbs that will do the same or whatever else is needed. We have moa, which really helps to consolidate and warm and activate blood flow within the muscle tissues. We have our gua, we have cupping, which, you know, cupping a little bit. Perhaps questionable considering there might be depletion, but it could be helpful in an isolated spot if there is particular tightness and over contraction.
For instance, if we have that imbalance that I talked about earlier with that serious anterior pelvic tilt and those back muscles are just. Squeeze down. The qls are just really tight. Those paraspinals are really tight and the abdomen is really stretched and the glutes are really stretched.
Cupping on that specific area could help to reduce the excess that’s in that area, distribute that throughout the body so that we can achieve a little bit more of a neutral tilt. We also have things in our tradition that are from the deep traditions of Chinese medicine, like pelvic steaming, like pelvic smoking.
Like abdominal binding, right? There are a lot of complimentary techniques that we can use to support our clients. Beyond that, if we get to know the pelvic floor in a deep way, then we’re gonna have the opportunity to support the pelvic floor, to evaluate the pelvic floor to. See where there are weaknesses to see where there are excesses, to see where we’ve got, stretch and tightening, right?
Because the left side and the right side might be different. Maybe the person who was having her baby had a leg length discrepancy, so everything on the right side, including the pelvic floor, is really tight. And then maybe there was a little tear going toward the left, and the left side is super duper weak.
So helping us to expand our practice by understand the pelvic floor really helps us to support these postpartum clients. So if you are with me today you probably know that this is my fifth workshop In my series we did a pelvic floor intro. We did a pelvic floor and menstruation, pelvic floor in fertility, pelvic floor in pregnancy.
This is pelvic floor and postpartum. We’ve also got a pelvic floor and menopause workshop coming up for you. Here are some references. I just wanna say, once again, thank you so much for being here. I really hope you enjoyed this workshop as much as I enjoyed sharing this material with you. Once again, I’m Dr.
Krystal Couture, the Pelvic acu, and this workshop has been sponsored by the American Acupuncture Council.
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