Tag Archives: billing and coding

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97140 for the Acupuncture Provider – AAC Info Network

 

 

And I always like to have a little bit of time to talk about what codes are billable, how do we build them? What do we do correctly? I think that’s often a problem, by example, what actually is manual therapy?

Click here to download the transcript.

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.

Okay. All right. I apologize for some technical difficulties, but welcome. This is Samuel Collins, your coding and billing expert for acupuncture, and specifically the American Acupuncture Council network, your go-to place for making sure you’re coding and billing are together. And quite frankly, your business sense. So if you’ve not checked us out, come to our site, but let’s focus in on what we want to talk about today. And I always like to have a little bit of time to talk about what codes are billable, how do we build them? What do we do correctly? I think that’s often a problem, by example, what actually is manual therapy? What does that mean? And how is it different? So let’s, let’s start here. Let’s talk about what manual therapy is. Well, part of dealing with CPT codes. I’m not sure if you’ve ever watched the show, the bachelor, and I’m a little embarrassed to say.

I have seen it not very much, but I, one time looked at the CPT codes and realize CPT codes are often simply like the bachelor. What I mean by that is you ever notice how kind of ambiguous sometimes they are. So think of it this way, the bachelor like CPT codes tends to be ambiguous, overlapping, and not clear to what their intent is. So think along these lines, when you look at these two codes and you’ll see here, I have them highlighted massage 9 7 1 2 4 and manual therapy, 9 7 1 4 0. How are those different? I mean, if you think of it, isn’t massage a manual therapy, isn’t it hands-on. And so that’s one of the issues we have to kind of deal with was where’s this differentiation.

So by example, take a look at these two pictures, the picture on the left picture, on the right, which of those actually would constitute bodywork. And what I mean by that is, is the one on the left massage, or is it manual therapy or is the one on the right? And there, I think is one of the issues I think we have to address for acupuncture providers is to really differentiate between the two as to what are we doing? Why are we doing it? If you will, where we’re doing it. And all those factors come into the coding and billing. Obviously body work is something that’s integrated into the acupuncture principles and traditional medicine for that matter. So let’s take a look. What is massage? Massage says, it’s a procedure that includes Effler Rouge, you know, circular motion, petrosal lifting and squeezing to potent stroking, percussion, even needing.

So again, kind of the standard massage things we all think of. And what’s the purpose of it? Well, muscle function to an extent, but if you think of it, probably relaxation, circulation, stiffness, uh, generically, it’s used to increase circulation and promote tissue relaxation. If you think about why do people get massages to relax that can help modulate pain a little bit. So, okay. So that’s the purpose of massage and that’s the style now, conversely, let’s talk about what is manual therapy? Well, let’s first look at the code manual therapy or the service manual therapy, 9 7 1 4 0. It says specifically in the CPT manual that says they are manual therapy techniques that include by example, mobilization manipulation, manual lymphatic drainage, manual traction, and it says one or more regions. Now that’s not a very big description when you think of it. So manual therapy techniques basically are hands-on services that go beyond standard.

Just simple massage, more, I would say deep tissue, if you will kind of to break up adhesions comparative to say just simple massage notice here, it includes things like manual trigger point therapy or myofascial release. Those would certainly be considered within that. Now let’s talk about it from a standpoint, how is it defined under the standards by the American physical therapy association? Since they’re the one that commonly used it let’s look at what they say. It says manual therapy techniques are skilled hand movements and skilled passive movements of joints and soft tissues that are intended to improve tissue extensibility. Now, I want you to notice here, the difference of that two massage massage said relaxation. This notice says tissue extensibility, and it says increased range of motion, induce relaxation. So there’s some overlap, modulating pain and reduced soft tissue, swelling, inflammation, or restrictions techniques may include manual lymphatic drainage, traction, you know, massage mobilization.

So you’re kind of going, well, wait a minute. They’re just kind of saying the same thing. So really how do I differentiate? What is manual therapy, comparatively? So types of manual therapy, well, manual traction. Is that something that acupuncturists might do? I think so joint mobilization. I want to be a little bit careful there because obviously you can’t do manipulation, but mobilization of movement certainly makes sense. And then there is of course myofascial release, and I think that’s the one we focus a little bit more on. So you notice here, a myofascial release says soft tissue mobilization. One or more regions may be medically necessary for the treatment of restricted motion and the soft tissues involved in the neck and extremities. So in other words, notice the emphasis towards manual therapy to be about tissue extensibility, that there’s restricted motion.

So manual therapy, what’s the difference? The difference is more about the goal of it. Obviously you put two hands on a person like those pictures I showed earlier, which is massage or manual therapy. It’s more about what you’re attempting to accomplish. So notice here, it says the goals of manual therapy are to treat restricted motion of soft tissues in the extremities, neck or otherwise, and restore soft tissue function or muscle function, meaning a restricted area. You’re breaking up the adhesions. So there’s normal movement movement without pain and increased extensibility. So you notice the keep emphasis here on extensibility. So how would you differentiate if you’re doing a hands-on simple squeezing, I would say certainly would fit massage, but if you’re doing it to break up literally adhesions in the muscles or restricted muscle that has now been shortened, that would be the myofascial release or if you will manual therapy.

So where do we fit that though with traditional medicine statements that include things like TuiNa or Washa? So TuiNa of course is literally the meaning of pension pool refers to a wide range of traditional medicine bodywork, but it’s considered probably the oldest. In fact, I would say everyone that’s doing massage is probably a form of this to an extent anyway. So with between a fit, as manual therapy or massage, well, I will say it could fit both because it depends on the level, the depth and what you’re trying to accomplish. So think along the lines of more, what is the goal of the therapy more than just because it’s hands-on, hands-on doesn’t necessarily mean it’s massage or manual therapy, but what you’re doing, but the why you’re doing it now, what about what shadow it says to scrape? That’s what it literally means. And it says a method in traditional or in traditional Chinese medicine, which includes the skin of the neck back.

And shoulders are limbs with dis lubricated and pressured or scraped with a round edge instrument. I think much like that. You’ve seen where people do these things called fascial abrasion techniques or breast in which I think often is just really a bastardization of Washoe to an extent. Now I’ve seen wash out, include a lot of things. So I want to be careful, I’m talking about that tissue scraping. Now, what would that purpose be? It’s done manually, even though it’s with the tool, it could be with your hand. Would that be more for a release than it would be for relaxation, obviously, an area that has an adhesion. You want to break apart that scar tissue that’s going to be more the myofascial release or the manual therapy. So what I’m trying to bring back here is that what you want to look at when you’re doing hands-on therapies to distinguish whether it’s massage simple or manual therapy is more about what is the outcome that you’re looking for?

What are you looking to change? So within that, I want you to think of purpose. What is the purpose of what I’m doing? That’s going to define it more in CPT. What they say is don’t choose a code that approximate, but what says exactly? So you might be doing a manual therapy. Let me use the term broadly, but yet it could be massage or it could be the more deep tissue work which equals the code for manual fare. Remember manual therapy was a code introduced in 1999 that replaced a lot of codes. It replaced traction, it replaced myofascial release. So it’s kind of a conglomerate code, but more meaning again for our purposes, kind of the deep tissue. So what I’d like you to think of is that when you’re appropriately coding for manual therapy, what is the purpose? If it is for tissue extensibility and range of motion, manual therapy after for simple muscle relaxation and pain modulation massage, okay.

Now beyond purpose, then I’ll go back to this picture, which of these is this massage or manual therapy? Obviously, as I mentioned, you can’t tell, but I will tell you the one on the right is the manual therapy picture. And the reason why is that one is being done to break up adhesions within the gastrocnemius and soleus in order to reduce restricted movement to the Achilles tendon. Whereas the one on the left, though, you could argue, what’s going to be, could be as deep that’s clueless, just relax the trapezius area in the shoulder region, if you will. So think of if I’m going to bill for manual therapy or provide manual therapy, just make sure you’re documenting the manual therapy. It’s hands-on but more about the purpose and the goal. So within that, what do you need to document? And this is really important part.

Obviously, if you’re billing for manual therapy, the big issue is that we have to show it. So documentation must be include that area. You’re doing the service also though, the or technique you’re using. And again, there could be a wide variety. Don’t be afraid of describing things like muscle, energy, PNF, things of that nature would fit certainly statements of myofascial release. What I want you to be careful of is don’t simply say I did manual therapy, identify what the styler technique was also indicate there, the start and stop times, or frankly, just the time. Remember this is a time service, much like is acupuncture. And so you do have to document time. Now you can document time. A couple of ways. You can just tell me how many minutes you spent, or you can do from into, if you say, Hey, I started at 10 and I ended at 10 20 of the 20 minutes either way, tell me how much time you spent because it’s time derivative.

And then along with that, the expected goals, and this is probably the more important factor to make sure you distinguish it from massage. I did myofascial release to the right shoulder to increase range of motion due to restrictions about the, you know, the clavicle area or the deltoid, something of that nature. Subscapularis you name it? Any of those would certainly be fit, but just tell me what the goal is. It’s more about the outcome then the service, could there be a mixture? What if you did some deep tissue work, but it also included a little bit of massage? Well, that certainly is fine. Just remember the bulk of the work would be the manual therapy. Therefore that would be the more appropriate code to bill. Now it is a 15 minute service and I’m sure you’re all aware. Does it require the full 15 minutes to bill for one unit just like acupuncture.

You do not have to spend a full 15 minutes face-to-face but at least eight minutes. So remember the eight minute rule does apply with this code as it would with massage for that matter. Now what it was billable here though. So here’s something I want to bring up about the eight minute rule. That’s often confusing. In fact, I did a program this weekend at the Florida state Oriental medical association. And one of the questions that came up was about timing. So I’m going to give you a little quiz here. Let’s see if you can pass. What is billable here? What if I do tend to 10 minutes, face-to-face doing acupuncture. You know, I insert some needles manual. And in addition to that, I do another 10 minutes of massage or manual therapy, either one don’t care. So I’ve spent 10 minutes on one, 10 minutes on it, the other, what can I, bill?

What will you bill for this visit? Can I bill for both codes? I’ll give you a moment to think about it, which is appropriate. Well, what is going to be appropriate? We have to do the eight minute rule. The time you spent with the patient, if you recall was 20 minutes total, remember 10 minutes in 10 minutes. Therefore, how many units is 10 minutes? We’ll look at this little chart and you’ll notice one unit is eight to 22 minutes. So if you only spent 20 minutes, can you bill for two units? And this is what’s important to remember, even though you’re doing two separate services, the time is cumulative. So if you’ve only seen, I spent 20 minutes, you cannot build both codes. Now you get to build one of them. Of course. And you always get to build the one that has a higher value, but you can’t build both.

So do make it important to always document time. Now, keep in mind. That’s because you spend 20 minutes. What if you actually spent, say 13 minutes on acupuncture and 10 minutes on the manual therapy would both be billable. Well, they would because you’ll notice two units is 23 minutes. So it becomes very imperative that you document the time properly in your file because frankly, that’s all someone’s ever going to look at. They’re not going to question so much the service as much as did you document it. What did you do? Where did you do it? And how much time did you spend?

So what about modifiers though? And this is a confusing area for acupuncturist because I’ve seen many of you say, Hey, do I need to have a modifier 59? When I bill this therapy? And the Frank answer is you do not. No modifier is typical on a claim for an acupuncturist when it comes to physical medicine codes for most plans. Now, bear in mind. Some people will think, oh, I have to put modifier 59. That is necessary for chiropractic providers, but it is not necessary for you. Chiropractors have to demonstrate a separate from manipulation, but not for acupuncture. So a 59 is not necessary on this code because it doesn’t have to be distinguished from something else. There’s no correlation of manual therapy to acupuncture. However, what but you want to make sure is is that though I don’t need to distinguish it from acupuncture. Are there some things we might have to do?

And this is something I want to make clear to not have anyone confused. We’ve done a program on this. You’ve been to a seminar with me. You’ve heard me talk about it as well. How about plans like United health care, Optum health, Anthem blue. Those companies require that when you build a physical medicine code, which includes manual therapy, you have to include modifier 59 or excuse me, modifier, GP, excuse me. So that true for all physical medicine codes. So if you’re billing a physical medicine code to United Optum Anthem, put a GP. Now notice, I didn’t say Aetna, I didn’t say Cigna. So don’t automatically add those in just because you’re billing, but to those carers only, but distinctively doesn’t acupuncturist need to put a 59 on manual therapy. You do not. There’s no need to distinguish it as a separate distinct service. So keep it simple, provide the manual therapy, why to reduce adhesions, increase range of motion.

If you’re doing it more for relaxation, likely massage bottom line is let’s make sure we’ve documented and build for it. Ultimately, if you’re providing a service, I want us to be reimbursed for it. I don’t think you should have a free clinic. No one has free clinics or at least at least no one. That’s trying to make a profit off of it. So I want you to keep in mind though. What about your state now? Of course, this is going across the whole United States. Now do most states have licensure for acupuncturists where they can do manual therapy or therapies? They do. By example, I’ll give one New Jersey has a very broad scope of practice, which clearly allows the service, but New York does not states like Florida do. And most states do so make sure you know, your state and what you’re allowed to do. But I will say generically, most states do allow adjunctive therapies and this can be within scope, but always check within your state to make sure am I practicing within my scope because some states do not.

So I don’t want to make this a blanket that everyone can do it because it may not be within your scope. Ultimately, what we want to be able to do is to make sure your practice can continue to thrive and enhance the care of your patients. I want you to do the services that are necessary for your patients to recover and get the best outcomes. Manual therapy certainly can be part of that. Let’s make sure we bill it right by documenting what we’re doing, where we’re doing it and the purpose. And of course time, ultimately we are your resource. If you’ve not taken a moment, come to our site, the American Acupuncture Council Network, AAC info network. We’ve got a new section there that is free to all of you. Don’t even have to be a member. We normally have a membership where I become part of your office.

I help you on a day-to-day basis with all types of issues, but we post a new section. So if you’ve not seen that, I would suggest take a look there. Cause we’ve got a lot of updated information on requirements for vaccines, whether it is or is not what’s going on with other issues regarding the ADA and other issues for acupuncture offices. So with that, I’m going to say thank you all very much. I’m glad to always spend time with you. Next week will be Virginia Doran and as always the American Acupuncture Council is always your resource as am I come and take a look, go to my Facebook page as well. And I welcome any questions from you. Thank you everyone. See you next time.

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What Modifiers Are Necessary On An Acupuncture Claim?

 

 

We’re going to give you always some updates on coding, billing, documentation, things to help enhance your practice.

Click here to download the transcript.

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.

Well, good day, everyone. This is Sam Collins, your coding and billing expert for acupuncture, the American Acupuncture Council and the American acupuncture council network. Welcome you to another program. We’re going to give you always some updates on coding, billing, documentation, things to help enhance your practice. Remember, our goal is the American Acupuncture Council is to always enhance you. We’re symbiotic. We obviously offer malpractice insurance, which I’m sure many of you have, but we also offer our network service, which gives you some up-to-date information. And this is partly what we do here is to make sure that your practice does well. So let’s get to the point. Let’s start to understand what’s happening in currently going on with modifiers. Let’s go to the slides. If they’re not up. Those modifiers that we run into often are very confusing for many acupuncturists. And there’s been some recent changes that you may not be aware of, that you probably have gotten some denials.

So let’s talk today about what is necessary for modifiers on an acupuncture claim. What do we really need? And believe me, I think there’s a lot of misinformation, unfortunately, and does not get you paid without the right information. So what are modifiers? What modifiers of course are referred to as what we say, a level one modifier and it’s to supplement information about the claim itself. There are usually two digits or two characters in line, and they tell us something specific about the service. By example, modifier 25 to indicate it’s a separate, distinct service things of that nature. So the modifier is there to tell us something more about it. In many ways, the lack of a modifier will cause a denial. In fact, I bet many of you didn’t learn about using a modifier 25 until you got up in practice and you were like, why do I never get paid for an exam is because we’re not using the right modifier.

Remember a modifier does not alter payment. It just indicates a specific specificity about the code so that it can be paid. And so where do modifiers go? This is a portion of a course of a 1500 claim form. You’d put the data service and notice here. There’s a section that says modifier and notice there’s four spaces, 1, 2, 3, 4. So is it possible that you might have to use more than one modifier? It certainly could be. It would be unusual in an acupuncture setting, but possible just bear in mind that you can always add up to four now, what is the most common modifier for acupuncturists? And this is the one I will say. Every acupuncture is going to use at some point and it’s modifier 25. And what modifier 25 indicates it says modifier 25 is defined as a significant separately, identifiable evaluation management service by the same physician or other healthcare, other qualified healthcare professional on the same date of service of another procedure.

So all that gobbly goop means that the modifier is required when you’re doing an ENM evaluation management or exam code the same day as acupuncture or any treatment to indicate that the exam was separate or above and beyond what we note as the pre and post service evaluation. So by example, when you see someone on a first visit, you’ve never seen them before. It is clear, you’re going to do a significant examination. You can’t just say, Hey, I don’t care. What’s wrong with you. Put them on a table and hit them with needles. But what you’re going to do is take their history, do a full evaluation. So that is clearly an exam above and beyond normally what you do. So that’s why on a first visit, when you build an exam, you always will put a 25 modifier. However, let me make a clarification.

Some acupuncturists have the misinformation that they’re going to do an evaluation management or an office visit on every single visit. And that is actually incorrect. And here’s why the acupuncture code includes a pre-service and post-service evaluation. So by example, I just noted the first visit. The first visit. Clearly you have the history of the injury. When did it happen? What did you do? All those things, but on a follow-up visit, yes, you are going to do a small evaluation. What are you going to do on a follow-up visit? Like if I were your patient on the second visit, you would say, Hey Sam, how are you feeling today? Is that better? Last time when you left, the pain was much less. So in other words, it’s going to do a review of the chief complaint that is called the pre-service. So the reason you can’t bill an exam every day is because the acupuncture code or actually any treatment code includes a small evaluation.

So the reason you’re putting a 25 modifier on the first exam is your notification to the insurance that this exam is above and beyond the exam associated with treatment beyond the normal day to day, how are you feeling better, worse tongue pulse and so forth. So again, an exam can’t be done every day, but there is an evaluation every day. That’s part of it. So for billing purposes, take a look how it goes. The modifier goes right next to the code and the mid-level exam, 9 9 2 0 3 and a 25. If you forget to put the 25, it is an automatic denial, just a hundred percent will not be paid. The 25 is there to indicate that it’s a separate and distinct service and payable. Doesn’t alter the price, but does indicate that it is a payable exam because it’s above and beyond the one you do day to day.

Now this, I will say every acupuncturist does no question, the first visit. And re-exams probably about every 30 days. Be careful do not build one each and every visit and also be mindful. Some carriers that you belong to, and that can include some of the blues as well as, um, some of the, uh, uh, United health care policies. Depending if you have a membership through like Ash, they may pay only one exam a year. So it’s not an issue that you didn’t use the right code or modifier check your contract. But assuming non contracted one should be paid. One done so long as you include the 25. Now you’ll notice I did put here a new patient exam, but it could be an established patient 9 9 2 1 3. So that again, most common one. Now here’s one you may not be familiar with, obviously, regardless of that, COVID seems to be tailing off.

Might there still be a use for telemedicine visits for an acupuncturist, particularly for a patient on their first visit. Maybe they don’t have the time to come in for an hour visit. So maybe you do the first half of the visit telemedicine meaning the non-treatment part. So how do you identify telemedicine? Well, there’s a unique modifier for telemedicine. It’s modifier 95. Now you’ll notice I have it right next to an ENM code because a telemedicine visit is an evaluation it’s counseling. So you would use an ENM code, but to identify it as telemedicine put a 95. Now, remember telemedicine does mean audio, video and live. It cannot be recorded as not a phone call. It must be live interactive, audio video. Now the one of a unique difference for this one is not just the modifier. You’ll notice. The place of service says zero to the zero to places.

Service indicates also a telemedicine setting. So it not only needs the 95 modifier, but the zero two, if it’s a telemedicine visit, now remember telemedicine. Obviously we can’t treat, but could there be places where there’s counseling for a patient where they can’t come in or let’s face it? What if they can’t come in timely or don’t have the time to spend an hour an hour and a half, which may be the history, might it be more convenient? Would it make more sense to maybe do a telemedicine, at least that part, and then follow up with a half hour visit where you actually do treatment. So a viable one they’re 25 on exams with treatment, but telemedicine 95. Now there’s another modifier. And this is the one I’m sure many of you have missed out on it’s modifier GP. I’m sure if you’ve billed the VA, you’re aware of it.

But what this modifier is called is called an always therapy modifier. It’s what’s called a HICPAC modifier, HCPCS healthcare, common procedure coding system. And it’s a letter one, and it’s always therapy because every time you build a therapy to some payers, they need to identify who’s providing it, meaning a therapy provider. So for acupuncture purposes, you’re going to use modifier GP. Now you’re going to think, well, GP indicates physical therapy. That’s true, but that’s within your scope. So you’re going to put a GP, not a geo or a GM, just understand geo means services by an occupational therapist, G N by a speech therapist. So for our purposes under scope of practice, it would be a GP. Now, what does this add on to literally every physical medicine rehabilitation code? So when you think of what is that, that’s going to be every therapy code, right?

We all the way from hot packs all the way through the unlisted service. So common services, massage, gosh, manual therapy, infrared heat exercise. In fact, what I will say is any therapy code that begins with the nine seven, not including acupuncture will require the GP and who requires it well United healthcare as of April last year, that includes Optum health. It also includes anyone going to the VA, which you’re probably already aware of, but here’s the newest beginning April 1st of this year. And I’m sure you’ve noticed it on a lot of claims going to Anthem. And this includes blue cross blue shield of Michigan notice blue cross of California. Now let me be clarified here for anyone from California in California, blue cross and blue shield are separate companies. So it includes blue cross in California, but not blue shield. So do be aware of that nuance and most other states they’re combined.

And that includes all of these states, including Indiana, Kentucky, Missouri, New Jersey, New York, Ohio, Vermont, and Wisconsin. And I think others as well. So check your EOB is if it comes back and it says this service is missing a modifier and it’s a therapy, chances are it’s the GP. Now that means all physical medicine codes. The question you may have though, is any other payers? Well, Medicare is one of them, but remember Medicare, we’re not billing directly, but technically if you’re looking for a denial for Medicare, you would put that on there, but again, not common. And so how does the code look like? Well, take a look here. You’ll notice I did an exam, same thing, but notice 9 7 0 2 6 GP. The GP does not change the price. It’s just a requirement for payment. So you may think, well, Hey Sam, can I add the GP to every client?

Why not just add it to everything? Well, that could be partially problematic. And I wouldn’t blanket it because there are carriers that may not recognize it and may deny it. So for now, I’m going to say Anthem policies, United healthcare and their affiliates and the VA a hundred percent. And if you ever get a dial back that says this claim for physical medicine services or physical therapy is missing a modifier, it’s likely a GP, but again, don’t Blake. It, it, because here’s what I’ve also found. If you put a modifier on something, they’re assuming you’re trying to tell them something unique and chances are, they may deny it. So for now stick with just those payers, if you’re wondering, well, how would I know this? One of the things you can do, the American acupuncture council is your partner and our website for our education division.

The network has a new section go to AAC info network, click on the new section, and you’ll see all these updates. It’s one of the ways we try to keep you up to date. So if you’ve never gone to the network website, please take a look, AAC info, network.com, click on news. And in fact, just sign up for our email subscription. And what we’ll do is send you once something has changed, because here’s the difficult part I come to you probably once a month or every other month, but what happens in between us, something has changed. So it’s our way of updating. So again, GP on all physical medicine codes, and we want to give you a portal where you can start to use it. Now here’s an area that I think is often very confusing and a lot of acupuncturists have bad information. They will say, Sam, do I need to use modifier 59?

Well, what does a 59? It says a distinct procedural service. And it says under certain circumstances, it may be necessary to indicate that a procedure service was distinct or independent from other services, not including an ENM. So a lot of acupuncturists have made this assumption that, oh, I put that on my second set. You absolutely do not. A second set is already distinct. There’s also another other modifier. That’s common. It’s more or less the same. And it says a separate structure. And it’s excess. Now I’m bringing this up to make sure you understand what these modifiers are and why you wouldn’t use them, because you do not have to indicate that the acupuncture is to a separate area. We don’t have that type of rule or protocol where I think this comes from is people not understanding chiropractic claims. And part of the unfortunate thing is often people who teach you are not teaching you specific things about acupuncture, but that’s something that may be related to what a physical therapist does or what a chiropractor does.

So let’s talk about specifically a chiropractic claim versus an acupuncture claim. Chiropractors have to use modifier 59 when they’re using massage or manual therapy. And it’s because the rule is a chiropractor is not separately reimbursed for massage or manual therapy. If it’s done in the same area as manipulation, hence why that modifier is there to show, oh, it’s distinct. It’s a separate area. Now this edit doesn’t apply to acupuncture. There’s nothing about acupuncture and manual therapy that will require a 59. So if you’re putting a 59 with it, there’s no absolute necessity for it. In fact, it may cause the claim to be denied. So as a general rule, the modifiers you’re going to use as an acupuncturist are going to be 25 on exam codes in GP. For those, those companies that I mentioned now, would you ever use a 59 will never for acupuncture, but I’ll give a scenario.

Some of you, you may be doing a little bit more of a rehab style with a patient. Maybe they have back pain and you’re doing some exercises and therapeutic activities. Particularly this could apply with a VA patient. If you were combining exercise 9 7 1 1 0 with therapeutic activities and 9, 7, 5, 3 0, you would put a 59 or one or the other codes to distinguish them as separate. And the reason why is those two services are very, very similar in fact, to be the exact same thing, but the outcome being different. So you want to distinguish that part of the service was, you know, exercise and part was a therapeutic activity. So that would be about the only place I would ever see the use of 59. So don’t get caught up that, oh, I have to use it. Trust me, it’s innocuous information and just incorrect. So again, 25 in GP, but not a 59.

And the reason I’m bringing up news, I’ve done a program with you before where I talked about Cigna at American specialty health, I’m going to let you know no, this doesn’t apply to California, Oregon, Washington, but to other states, if you’ve not seen it, they’ve delayed the change to September and they’ve upped the ante to 89, a visit from 55. So that’s a nice change. You should have received some information on it, but if you have not, how do you find out go to AAC info, network.com, click on the news tab. And you’ll see, I’ve written an article piece on that. Our job at the American Acupuncture Council, keeping you up to date, keeping you paid keeping to make sure your practice survives. So if you’ve not been to our site, this is the site. Notice here, the new section, click on that. You’re right in.

But let’s talk about what are you doing to really make your office do well. Have you ever thought of where do I get my answers? Who do I get them from? Hire an expert. We offer a service called the network where for a small fee per year, you get complete access to me where I become part of your staff. You can ask me questions on coding, billing, documentation, medical necessity. Hey, Sam, a claim got denied. Get to a place where we’re making sure your claims getting paid. Here’s what I guarantee you. Join our network. I’ll get your money back within a month because all I have to do is answer one or two questions and it’s always related to money. You’ve gotten paid back and it’s going to be triple fold because guess who gets notified? First people who are in the network, we send out an email chain to everyone.

That’s a network member when something’s changing. Anytime there’s an update. You’re notified first. So let’s help you get your claims paid, go to our site. Here’s a QR code you can go to, but simply go to our site. AACinfonetwork.com. We’re here to help as always the American Acupuncture Council is your policy holder or your policy holders, but we’re also your advocates. Now next week’s program will be Virginia Doran. I look forward to seeing you all next time. Take a look at the site. Let’s get you paid and best wishes to everyone. Thank you very much.

 

AACTTPCollins03242021 Thumb

CIGNA ASH Update for Acupuncture Providers – Sam Collins

 

 

Well, as always, let’s kind of work with what’s going on and changing for us in the realm of coding and billing. And specifically this episode, we’re going to spend some time with American specialty health and Cigna.

Click here to download the transcript.

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.

And we’re Live. All right,

Greetings everyone. This is Samuel Collins, your coding and billing expert for acupuncture and the American Acupuncture Council. Welcome you to another episode of, to the point by the American acupuncture council. And thank you for spending some time with me. I will always want to give you some updates. What’s changing. What’s going on. What’s new. If you have not, please take a look at the American Acupuncture Council Network site to check our new section. Cause we do update information there. Along with these shows. We also have information on our Facebook page too. If you’ll take a look there. Well, as always, let’s kind of work with what’s going on and changing for us in the realm of coding and billing. And specifically this episode, we’re going to spend some time with American specialty health and Cigna. Cause I know a lot of you have gotten some letters, so let’s go to the slides, everyone.

All right. As always here’s our website, of course, we’ll take a look there. That’s where the new section is, but let’s kind of focus in on what’s been going on or what is going on with Cigna. So let’s take a look at this letter that I’m sure many of you received. Notice. This one is just dated February 26 and it says here Cigna is pleased to announce that they are expanding their acupuncture per provides our customers with access to services effective June 1st. Now let’s read this thoroughly because it says we encourage you to become a participating provider with Ash to support acupuncture services for Cigna customers, benefits plans nationwide beginning June 1st. So let’s start first with notice. It says encourage it. Doesn’t say we require. In addition, it says as a result of this program, this will contract directly with providers for acupuncture services for Cigna benefits.

Now, for those that are familiar with American specialty health or Ash, it is one of the largest plans out there that manages typically chiropractic acupuncture as well as physical therapy. And most people often will give a kind of negative outlook to this company. Now I want to be careful. I’m not saying they’re a bad company, but the one factor that many people focus on is that they simply have a very low reimbursement. They do have some other requirements, but as far as being negative towards it, I’ve heard people say it’s not so much the company. I think they’re fine. It’s just the reimbursement as well. So it says here, we’re going to use that company, which means reimbursements are going to decrease based on this. And it says, provide contract administration, medical necessity, review, and claims processing. Now I will say this. They have a very good plane claims processing portal that can make things easier.

And actually if you use their portal, they actually give you a bonus payment. So that’s pretty good. Don’t get too excited. That bonus payment is literally pennies to a dollar nonetheless. Um, this is what’s occurring now. What’s important. It says we encourage you and then notice here. It says what this means to you. You must be contracted with Ash in order to provide in-network acupuncture services. So what that is saying that if you wish to be in network with Cigna, you must Ash. Now. Sure. Some of you have been through the program with Accu care, maybe a couple others that were handling this. They’ve just simply moved the contract over to Ash. So does that mean they won’t have benefits? No. It just simply means that if you want to have in network benefits, now this is where we really have to decide how well this is going to work.

Now it says here about advantages, continuity of care, access to their Ashlyn, which is their, um, billing portion, no fees to join. That’s all good advantages of a hundred percent, a hundred percent. Peer-to-peer here’s the downside. The downside is they’re often very strict when it comes to medical necessity. Now I’m not saying they’re too strict, but you have to remember, they’re going to look for how well is the care working? What are the changes being made? So it’s something you really want to start to take a look at as to whether or not that’s something you can work with or how many visits you see. Because often after five visits, they’re going to request additional information, which I will say is terribly hard, but it doesn’t mean that’s going to be extra work. And we have to decide whether or not this is going to be a benefit we want.

Well, there’s a second part to the letter and something I want to emphasize here is this. It says for applicable areas, this is not going to include California, Washington, state, Oregon, or Tennessee. So those areas already have contracts with Ash. So you won’t necessarily have to join, but the benefits can be managed there. And it’s not including benefits for North Carolina and Virginia, which they say are upcoming. So what they’re saying is if you want to join, they’re looking for you to join sometime around April 1st. Now that’s when you can begin, do you have to join for you to have these benefits? Is what my concern is. The answer is simply no, the patients will still continue to have the benefits, but what will it pay and how do we decide? So here’s one of the things we do. I do seminars, of course, I’m sure many of you have attended.

And I also have a consulting service that our network that I work with you one-on-one. Well, one of the things you have to do is kind of do what I do with my members. And that is to figure out how worthwhile is it to be a member of this? Let’s start to talk about it this way. I’m going to keep this kind of simplistic for the timeframe we have. But think of it this way. When you join Cigna or Ash, you’re trading something now, what are you trading? You’re trading generally, you’re going to get less money per visit, but more patients. That’s kind of the advantage. If you’re in network, are you going to get considerably more people? So one of the things to consider is how does Cigna patients come to you in the first place? Were they coming to you because you were in network with something or were they simply coming? So in other words, if you are already getting the patients, how has joining going to bring more? In fact, my concern would be, if you join, you simply are going to get less. So the choices, if it can give you much

More volume and will it make up

For the decrease in reimbursement. So let’s talk about the in network and out of network in network means you’re controlled to those fees and you may not collect anything different other than what’s allowed. If you are out of network, they’re going to pay what they allow, but then you can balance bill the patient. Now that balance billing is fine, but how much will the patient take? How much can they afford? Would it be better for them to go to an in-network doctor where they have to pay maybe a $15 copay compared to coming to you where it could be $40? So that’s something to consider. Although I will say this, don’t be afraid to offer your patients good service. People don’t choose acupuncturist because you’re cheap. They choose it because you can help them and make them feel better. And there’s a value to that.

So before we begin in talking about what the fees are of this thing, let’s talk about joining. When you join, you have to wait out what what’s good. What’s bad. So I suggest take a piece of paper, draw a line down the center on one side, please. Yes. On the other side, put no and start looking at the potentials. One thing to start with is, is this plant exclusive? Well, I’ll start with, it’s not, so that’s going to be a no. Why would I join something? That’s non-exclusive unless somehow it could send me many more patients. So I’m going to check a no on that one because it’s not exclusive. The next thing says is the pay reasonable? Well, I’m going to show you in just a moment. Not very now. I’m not going to say it’s horrible, but it’s not very good. So that’s already two there.

The only thing I could think that this would do for you is bring you a lot of new patients. Because if I look under the note, it’s, non-exclusive, it doesn’t pay very much. If they’re already current patients, how does that help? And there’s other requests they have after you do a certain number of visits, probably after five years, I have to do what’s called a treatment authorization. So this is, there’s a lot of downside to this in the sense of the extra work. Not saying it’s too hard, but please go in with your eyes open. I want you to think of the value. Well, let’s talk about what does it cost to treat a patient in your office? By example, let’s say your overhead per month is $4,000 and you see about a hundred patient visits. It’s a month now, again, that’s 25 a week.

That means it costs you $40 just to keep your office open on those number of patients. So by example, under some of these Ash policies, they pay 1550 $5 max per visit. So therefore if you’re getting $50 or $55 max, that means you’re making only 10 or $15 per patient think of how much extra volume. So in other words, if you have only asked patients, you’re going to go broke this one, you have to be a value added patient. And maybe this is where this can make a difference. Can it bring you someone that you have not already seen that will be new to your office? My key factor is going to be, does it really bring that type of value is the trade-off worth it? Well, let’s take a look at what they’ve done in California. Over this past year, American specialty health has worked with blue shield of California.

And what it allows is a car, an acupuncturist to do ENM codes. So exams, acupuncture in some objective therapies. Well, that sounds pretty good. Realize too, this plan doesn’t cover massage or TuiNa. So those services can be built with a patient separately so long as you inform them beforehand. So that sounds good. Except when you see, well, what’s the allowance. Well, even though they say they cover all of these things, the max per day is $55 and it’s inclusive and all visits count towards. So if you have a patient come in and get one service, it’s going to count as a complete visit. There’s no like, Oh, I just did a therapy. It’s still going to count. So here’s their allowance. This is the California. One $30 for exams essentially. And then 20 to 30 for re-exams. Okay. Not bad, but remember that’s still within the max.

So you’ll notice here. The plan says it pays $55 max per visit. Well, isn’t it interesting that the first set is 45 and the second set is 10. So in other words, as soon as you do two sets, you’ve maxed out. Even if you did an exam, do you get paid separately for that? Nope. The max per day is still 55. So therefore there’s really no additional benefit of them to think it’s paying you 55 per visit. Even the therapies you’ll notice are $10. So therefore, even if you did these therapies plus the acupuncture, what are you getting? Pre-visit 55. Now I’m not attempting to sound overly negative. I’m just saying, be aware of what the plan pays. This particular plan with Ash in California pays $55. Now American specialty health does do a medical necessity. And I would say, this is something I believe they’re pretty good at.

They kind of look at the patient. Yeah. As an overall, what do they cover? Things like headaches, hip or knee pain with arthritis or not extremity pain, mechanical irritation, pain, syndromes, back and neck pain. And of course not vomiting. And of course, you know, that Cigna has one of the most prolific diagnosis, allowances of all plans. I don’t foresee that changing the concern is how much, well, how much also relates to, well, how many visits are you going to get out of this? What they do pay attention to is your diagnosis understand less severe diagnosis. Don’t get as many visits, back pain compared to, let’s say a disc injury are very different. They do pay attention to things like this. And when you do your authorization, keep in mind indications in their history, such as it acute or trauma or traumatic chronic. Those make a difference.

A patient with comorbid factors, things that inhibit their recovery should be brought up. But when you do an exam, anything, you do the range of motion, palpation, orthopedic testing. If you do it, neurologic testing, quantify it. Don’t just tell me it’s positive. But also they do pay attention to tongue and pulse. So I’ll give them credit. They do follow some traditional principles. However, at the end of the day, what they’re looking for is can you show that you’re making the patient better? So understand that for $55 after five visits, do you have to do more of this information to get additional visits potentially? And it depends again on severity of diagnosis, they also look at the goals, how are you going to get the patient better? Well, let’s look at what this Cigna proposal is. And I couldn’t put the fee schedule up because it says it’s proprietary, but this is one I received from the, uh, Idaho area.

And, and I should say Midwest. And so you can see here, it’s not much different than what I just showed you. The 33 to 44 exams. The acupuncture they’ll notice here are going to be far cheaper. They are doing $40 for acupuncture. And I want to point out, I put a mistake here. This should be 40, not 45. The additional sets are paid for nothing. They’re just certain inclusive. So if you do one set or 10 sets, you’re going to get the same money. So something to consider when joining these plans, if you are a four set type of provider three set, this is going to be hard to absorb because that means you’re spending 45 minutes with a patient and getting $40 of reimbursement. Now, what if you’re the type of provider that does one set can be efficient. You needle the patient, make sure they’re finding, maybe they rest for a while and you’ll come back kind of a battlefield acupuncture or modern acupuncture style.

Maybe it can work because you can do volume. The difficulty is how much volume can you do? You know, at some point there’s a finite amount of things that an acupuncturist can do. Well, here’s what their fee schedule. Again, same thing for acupuncture and for therapies. So notice $10. So again, what is the maximum per visit? Well, it’s going to be 50 assuming, uh, acupuncture and a therapy. What they haven’t made clear, will they always pay the therapy separately. Now here’s for the region for the East Eastern areas. This is when I got out of DC. You’ll notice about the same prices, prices a little higher than the Midwest, I guess, but then you’ll notice fees are all the same. So what I’m going to suggest when you get into this, notice every therapy. Now the thing that frustrates me with this is how do you justify charging $10 for a hot pack and then $10 for exercise.

When exercise requires one-on-one care, that’s detailed undocumented compared to just lay in a hot pack on someone. How does that seem reasonable? So my bone to pick here is they should be paying providers more. And so I’ve had a lot of providers asking me, Sam, what I joined this? Now, all I can say is I’m going to give my opinion. Each of you have to make a decision on your own, how well this works. If you can do a high volume practice and there are a number of patients that are going to come in, only because they’re in this space, it could be worth it. However, if you are a two or three set provider, right, and you’re getting only $40, that’s going to be hard to swallow, but here’s the point. If you’re out of network, is it going to be the same thing?

Anyway, the difference is you can charge the patient. And what I’d explained to the patient is your plan pays $50. My visit is 80 and what you’re going to get with my visit is a much better level of care. I will be able to spend more time with you and really correct it as opposed to what I call a poke and run doctor, meaning, put the needles in and run out. Now, I’m not saying that in a negative way, there’s places for all types of providers. I could just find this very hard to work with now, how is this going to work? If providers do not join, will they still have benefits? Nothing has been shown from Ash or from Cigna. That patient we’ll lose benefits. If they go to out network providers, I think mostly this is a way to get the PR profession to join where they are going to gain more control.

Now I’m not against the medical necessity side. I think that’s fine. I just think that this reimbursement level is a hard one to sustain a practice. Let’s face it. If all you got were $50 from every patient and you spend a half hour with every patient, that means you make a hundred dollars per hour, assuming everything works efficiently or 800 per day, you can say, Hey look, that’s 4,500 per week. You know, or knowing that 4,500, excuse me. Uh, but those amounts could I, well, there’s 4,500 per week. Could I make that work well? Sure. But that’s, if you’re very efficient within that. So is it terrible? No. Is it really commensurate with what they were already paying? I don’t think so. And so that’s something that as a provider, you’re going to have to look at and decide, is it worth it to me now?

I will tell you, I’ve given you a little thumbnail of information. I tried to get it out there to you to get a little understanding. If you need more or want more, we offer services to do that. Our seminars at the American Acupuncture Council do that, but also we offer a service. That’s called the network. Just take your phone, scan this, come and take a look at the services we offer. Allow me to be part of your team where you can call me, email me, text me, or fax me questions. And we can work this through the, see how this is going to work and how to make sure you can keep your practice viable. I’m not going to be overly negative, but I want to say that obviously this is going to create a much greater level of control with much lower reimbursement. And that’s something I’ll say it’s not a positive for the profession.

So I’ve gotten a lot of feedback from different States and I’m talking to their state organizations where they have surveyed and a large number of providers have indicated they’re not going to join. It’ll be interesting to see if there’s not very many, what will Ash do or Cigna? All the patients will still have access to benefits. So what I’ll say to you is make a good decision for your office, make an informed decision. And the good news is what if you do join or don’t join. Can you always go back and change your mind? Sure. You can always go back and drop out or join. You want to do what’s best for your practice. Remember you are important to your patients and it’s good to be important, but it’s more important to be good. And to give that good service, you want to make sure that you have a viable practice to do it, allow us a chance to help you, but also the American Acupuncture Council is always here for you. Next week’s class is going to be with Poney Chiang. So pay attention to that. Otherwise I’ll say to all of you, best wishes, keep a close eye out and don’t be afraid to take a look and decide to be or not to be if you will. Thanks everyone. I’ll see you next time. This is Sam Collins, your coding and billing expert.

 

Sam Collins for AAC02102021

Do Not Risk Loss of Payment! – AAC Infonetwork

 

 

I want to talk to you a little bit about what’s been going on and I’m sure many of you have noticed on what’s called the medically unlikely edits or the limits to care. And I’m sure some of you have seen it.

Click here to download the transcript.

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 Samuel Collins, the coding and billing expert for acupuncture and the American Acupuncture Council. But most importantly, the coding and billing expert for you. While I do have roles with the world health organization, United healthcare and Optum health. My ultimate goal is for the practitioners just as American Acupuncture Council is, and this is another addition to make sure that you’re getting things right, understanding what’s going on, promoting your practice. And I do the billing side I’m with the American Acupuncture Council Network, which means we’re part of the malpractice side that really helps you with the coding, the billing, the education and seminars we’re here today. I want to talk to you a little bit about what’s been going on and I’m sure many of you have noticed on what’s called the medically unlikely edits or the limits to care. And I’m sure some of you have seen it.

Hey, why are they denying? In fact, we’re running into some areas in New York where they’re paying only for one, which actually shouldn’t be what’s there others paying for two or three? Well, what is correct? What do we have to make sure we’re doing to make sure we are getting paid fully, but also making sure if they don’t pay us, what do we do about it? And where does it come from? So let’s go to the slide. So you can start to take a look at what’s happening. So in these slides, you’ll notice I have here. It says acupuncture, medically unlikely edits. MUE is what they term it. And what that deals with is the maximum number of services that can be done per day. And that’s not just for acupuncture acts. So that includes physical medicine and other services. And also want to hit a little bit on to medical necessity, cause that’s really kind of where this dovetails.

So if you take a look here and I know this is smallest, let me enlarge this a little bit for you. You’ll notice here. This is from empire blue, cross blue shield. And notice what they’re bringing to this doctorate says the review indicated your average utilization of acupuncture sessions of one hour or greater personal one-on-one contact with a patient is higher than expected. So that means you’re doing an hour more so than everyone else. They’re not saying necessarily it’s wrong, but because it’s above average, they’re trying to figure out why. So notice in the next paragraph I highlighted it says, we are aware of many factors that may impact the coding of your acupuncture services. Our goal is to assist providers. So they’re not necessarily trying to be punitive, but trying to figure out why are you doing more is for too much, not necessarily, if you talk to most acupuncturist and I’ve taught seminars now for 23 years.

And I would say the average acupuncture is probably does between two and three sets regularly. So four is not unheard of, but it’s not typical, but I would say the average is two or three. So when it goes to four on a very regular basis, there could be some issues. In fact, this is probably where the medically unlikely edits come from. Well, let’s talk about it from a medical necessity standpoint, if you’re going to do ortho, that’s why that’s part of what we have to determine. So I’m going to give you what medical necessity is determined by the company, American specialty health, which I’m sure a lot of you have a tendency to. There’s kind of a love, hate relationship with them. I don’t think the hate is so much from the protocols is just, I wish they paid more, but ultimately I do think they make a nice protocol for what they determine as medical necessity.

So always understand when you’re going to do four sets or more, the Y has got to be based on the diagnosis. The severity of the problem. Now the difficulty with diagnosis is often the diagnosis for acupuncture is simply just pain. So how does that really demonstrate severity unless you’re coding like a lumbar disc. It really doesn’t. So remember your chart notes are going to be an important factor. The past medical history of the history, including is it traumatic? Is it repetitive? Is it acute? In other words, severity, what’s also going to be part of that though, is comorbid factors. Things that can complicate the patient, things that are underlying patients, very overweight patient has a very poor diet. Patient is diabetic. While you may not be treating those things directly, could they affect how the patient responds? Meaning why did I do four sets, other things?

They look at our range of motion, palpatory findings, orthopedic testing, neurologic testing, but they also do look at the tongue and pulse notice all these say quantify. Cause we want to know, well, if it’s severe, these things would all be more severe as evidence and quantified do. Remember they will look at the functional limitation, how the patient is getting better or not better just stating the patient feels better is not going to be enough. We have to be, how is it better? What can they do now that they couldn’t do before? And there’s always going to be goals for it. So ultimately think of medical necessity as kind of looking at how you would see a patient overall in their improvement, not just paying level. And there’s something to think of. This is from a company called health partners and I liked the way they put together the factors that they look at for medical necessity, things they put in mind.

Notice the first thing, gender fatigue, lack of energy, notice mobility, agility, strength, sleep issues, not falling asleep. You know, not waking up feeling rested or just the decreased quality of life. Those are factors that if you quantify given issue of potential severity beyond just stating pain, now I bring this up because of course, if you’re going to do acupuncture, we know that there’s four codes and you know that the four codes are there to allow us to build additional services when necessary. Some patients may get one, two, three, or four, but what’s important to remember is that acupuncture requires two things for billing purposes, for billing purposes, you’ll notice the acupuncture code says one or more needles, which means you have to insert a needle. But then it also says initial 15 minutes and each subsequent code says the same thing. It says reinsertion, which really should be additional insertion and 15 minutes.

So the codes are really going to be based on inserting needles and spending time. So if you’re telling me that you’ve done four sets, that means you actually have to be in the room with the patient for the full fifth, 60 minutes or close to it and do four distinct insertions one in the first 15, second, 15 and so on, which is not something that you wouldn’t do, but you have to document it and let’s remember, and see here. It says how the 15 minute session is defined. Remember, as soon as you walk in the room with the patient, say, Hey, how are you feeling today? The time starts, all the things you do. That’s part of your acupuncture, including review of history. Hand-washing choosing points. All of that counts. What’s important is to document it because you’re doing multiple sets. The one issue we’ve run in through the American acupuncture council is offices.

Aren’t documenting that well. So that becomes a problem. Well, it’s also a problem just based on number. So let’s take a look here and I’ll show you. This is an example of a soap note for acupuncture that has documented three sets. And I want you to see here, and I don’t want you to really comment about necessity. Just show how it works. Notice each set is identified set one, two and three. Notice the points are identified in addition, the face-to-face time from and two, or it could be minutes and then retention. So clearly when you see here, you’re noticing there is clearly three sets because there’s three separate insertions as documented notice the face-to-face time equals hitting the eight minute rule, if you will. And then it shows the separate retention. Remember don’t count retention towards the total time. So if you’re doing multiple sets, we have to make sure that we’re documenting all those factors. Because if we’re doing two, three or four, it still has to be shown. Did we do it? Well, this brings me to this kind of medically unlikely edits or what CPT does is they do edits for all types of codes. And there’s two types of edits that are common.

The first one is called the correct coding initiative at it. Yeah,

That is one that the correct coding initiative edit is one that there we go is used for coding, such for chiropractors, like a chiropractor. When they Do manipulation, there are codes that are part of manipulation That have to be separately coded. So by example, they Have to not code nine 71, four zero With manipulation. This I apologize. My phone is,

But you have someone who keeps trying to call through. So I apologize That these coding initiatives, goodness, here we go. And my apologies for this, I Cannot seem to get someone to understand what a message says. I’m not available. That I’m not Nonetheless, they kept trying let’s do this.

Okay. My falsies bear with me, correct coding initiatives. Just tell me what codes can and cannot be billed together. Okay? So for chiropractors, that’s common for record Puncture. It’s not, but we’re acupuncture does help.

Some common issues. Common issues for acupuncturists are under something called the Medically unlikely edits.

Medically unlikely deal with codes that can not be coded for an excess amount of units. Now you may think, what does that mean? This is where it comes in. You’ve noticed where they’re saying acupuncture can only be billed for say three sets or two sets depending on who you’re dealing with. That’s what they’re referring to. So what are you Louise there for any CPT code that the maximum amount of services that will be provided under one visit or a date of service, this applies to all types of codes. So by example, to show you where it’s also applies, it’s not just for acupuncture. Things like modalities have one, some have four. If it’s an attempt to Allie, when it’s timed such as notice the here it’s just the unattended services or one notice the codes for electric STEM allow for, but then ultrasound is only two. And again, that’s just based on these edits that say that’s the maximum per visit we’ll procedures. Get a little bit different. Notice for exercise nine, seven one one zero. It is six

For neuromuscular education. It is, it is for

Because it’s a little different service than exercise. So they’re limiting to four notice massage only four. Now you may say who comes up with these it’s part of the coding committees edits that do such. So make sure that you’re using the correct codes and amount of units. Now I doubt many of you go well above that notice manual therapy says six. So these are what they’re going to indicate as the amount that you can do maximum per day. So if you did more than six, they’re going to say no. Well, where does our services fit? You can see here therapeutic activities, by the way, I chose these codes here on the right side specifically because that’s the limits for those codes. But also those are the codes. If you’re billing VA patients, those are the services that the VA will automatically authorize for acupuncture providers.

But here’s what we’re running into. As I mentioned, the VA, take a look here. Here’s what’s called the standard episode of care SEOC and you’ll notice it says for acupuncture 12 visits, but notice it says a maximum of one additional unit of acupuncture with, or without electric STEM when reinsertion of needles. So under this one, and this is an Optum health, when they’re saying, Hey, you can only do two. And I’m sure many of you have run into that. Whereas before you could do four or five, it’s just saying they’re allowing only two. So that’s OptumHealth now again, that goes against what the normal edit says, because notice this one from tri West and you’ll see, this is really just from December. I know you can’t see the date, but you’ll notice here. It says the maximum unit

Acupuncture. And you’ll notice the map

Maximum units for acupuncture indicate nine, seven, eight one zero. The first set is one unit, but then the additional sets notice are two. So notice they’re indicating under this correct coding under the many medically unlikely edits. The limit is three, meaning one initial set and up to two additional sets. Now to give you a little history of that, that hasn’t always been the case. I want you to see here. This comes directly from United healthcare, and this is dated notice 2018 through 19. And it was different. It says the medically unlikely edits indicated that you can do one initial set, but then three additional sets of manual. And then electoral was one and two only. So three total. So at that time it was four, but let’s fast forward to this year. You’ll notice again, this is the health care notice from 2020. And now it’s indicating that according to this edit notice here, it says the policy enforces the code description for acupuncture services, which are to be reported based on 15 minute time increments, personal face-to-face time.

And it’s indicating in accordance here nine, seven, eight one zero is one. By the way, one makes sense. You can only have one initial set, but then notice instead of it being three, it is now two. So that’s also two here. So what is the new rule for medically unlikely edits for acupuncture is three. Now what if you say Sam, I need to do more now. Medically unlikely doesn’t mean an absolute, could you defend doing more and request more? Sure, but now you’d have to show the medical necessity of what did my fourth set do that wasn’t completed within the first three sets? I think there’s some things that can be disputed there, particularly if you’re doing front and backside sets multiple diagnosis, but again, you’d have to kind of come up with what is the fourth set doing that the others aren’t simple answer.

If you build three, you should not have much problem, but we’re seeing issues here. This is a United healthcare, and you’ll notice on this visit, they’re paying the one initial set they’re allowing it, but then notice this one they’ve taken out. It used this code in three, six, two. So what does [inaudible] mean? Well, let’s look at this full EOB notice in three, six, two says the number of days or units exceeds our acceptable maximum. So let’s take a look at what there are allowing notice on this one, visit on 10 27, they’re allowing the initial set, they’re paying the full amount or allowing it, but then on the additional sets they allow the nine seven eight one one four one and nine, seven eight, um, one, one again, but then not allowing the third set or the third or four set, which would be the nine, seven eight one three.

Now, even this one here, what I’m trying to point out is that they’re beginning to say, Hey, we’re not going to pay more than three if you bill such. So you want to make sure that if you’re billing more than three chances are with some payers. And I will tell you anthems Cigna, Aetna, as well as United have begun to really follow this as well as the VA. So what do we need to do to make sure we’re getting paid properly is to make sure we’re number one, sticking within the three. And if we’re going to go more than three, we’re going to have to send explanation, but here’s one of the problems we’ve run into. There are some plans, even like this one that they’re not paying that third. So when that happens, what’s going on. Here’s another one and this is an empire or excuse me, a Cigna, excuse me.

And I’m just going to blow this up so you can see here. It indicates the number of units built for this service exceeds the limit for the day. Now, if you look at this bill though, they’re allowing the first set and the second set, but not allowing the third. So then wait a minute. Why are they not allowing that amount or excuse me, they are allowing that amount. I want to share this one is doing three. So there’s one initial one, follow one follow. But then the fourth is saying no. And that comes from those edits. If you were billing more than three, you’re very likely to be denied for the fourth. Some payers may allow, but most are going to follow these edits. But what if you’re running into an issue with it where you’ve billed only three and they’ve denied it, then I’m going to push back.

Here’s a letter. And you know, you’re welcome to kind of see how it does. It just brings up the points of I’ve recently received a claim for payment that was denied due to the medically unlikely edits. And you’re going to bring up the medically unlikely edits indicate that there should be three. So if they’re only paying for two, this is the response. You have to say, the medically unlikely edits indicate three, unless you have a contract otherwise. And I’ve seen a lot of plans doing this. And I think what’s occurred is a lot of them have misinterpreted the edits and somehow are allowing to, so you want to make a little bit of a pushback. In addition, for those of you who are billing Optum, when you’re billing, Optum, meaning VA, and they’re only allowing two, here’s my concern. How is the Western part of the country try West allowing three and the Eastern part of the country only allowing two yet.

It’s the same, the same benefit. And of course it’s because Optum has misinterpreted it and there should be three. So this is a little bit of the pushback. Is this something I’m very excited about? No, I don’t like to see any limitations, but we have to know what we’re working with now. The good news is three sets is pretty typical that most aren’t going even that high. In fact, I’ve taught seminars now for 20 years. And I would say on average, when I asked the room, how many people are doing four sets, it’s a very minor percentage. But when I ask who’s doing two or three, it’s most so again, if you’re sticking within two or three, this may not make much of an effect, but if you’re doing four, a Canon may want to rethink of what’s going on. Now you can see, this is what I’m here to do is help you understand it, help you fight back with it.

And I’m going to say, give me a chance to help you do that. The American Acupuncture Council is your resource for these courses, but also I’m a resource. Allow me to be part of your office, take your phone out, take your camera and just put it over that code. And what that’s going to do is give you an opportunity to hire me for your office, but we’re going to give you the first 30 days for no charge. Give me a trial. Let me help you with a claim. Let me help you show what’s going on. Realize these rules and codes. We have fight back letters and all types of things that we can do that I can aid you and making sure you’re being properly paid and not having something where your claims are constantly being denied. Think of how many times you’ve had denials for ENM codes or other services that were not correct.

What do you do about it? I’m going to give you the rules and the laws, not opinions to fix it. The American Acupuncture Council is your resource. Allow me to be part of your office. You can join for as little as $25 a month, or you can do it with seminars. So I’m going to say, take a look at the services we offer I’ll guarantee you’ll get help. In addition, take a look on our site when get there. I’ve got videos and things of other things that we have done and looking at our news section for updates, we are here to help and I want to make sure today you understand what do I deal with and how do I deal with medically unlikely edits? What do they mean if I can do three great, but what if they’re cutting me less than three? But what if I do four?

How do I fight back for that? So that’s what we’re here to do is to help you for that. So I’m going to wish you well and say, stay tuned next week. The, um, host will be Jeffrey Grossman, and I’ll see you next time. I hope I become part of your office. Take a look at our site, take a look at the services we offer. We’re here to make your office successful. Don’t guess let’s make sure you’re getting paid. We do much more than just simply tell you a code. We make sure you’re doing it right. Thank you everyone.

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