Tag Archives: billing and coding

CollinsHDAAC06082022 Thumb

Cupping – Coding, Billing and Reimbursement


YouTube player


how do I code for cupping? Can I get paid? What is the proper code? Let’s really get into that.

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 Sam Collins, your coding and billing expert for acupuncture and the American Acupuncture Council Network. With our other episode on always looking to continue to grow your practice, to give yourself more opportunity, to see people and help people. And as always, I’m going to give you tips on coding and billing and really practice management.

This is a great time to be an acupuncturist, but how do we make sure we’re getting from gaining full advantage to get access to patients and the services we provide? So what I’d like to do with you today is to talk about coding and billing specifically for cupping. This is one that I get this question a lot is that seminar producer, as well as doing our network services, where people call them with questions.

One of the questions I get is, Hey Sam, how do I code for cupping? Can I get paid? What is the proper code? Let’s really get into that. So let’s go to the slides. Let’s take a look. What’s going on with. And how do we do it? What’s the coding and billing. Please note, there is our website. This is the network, not the insurance company, ACM phone network.

Remember we always have updates and news for you there. So what are we looking for? What do we need to do? What is. A cupping as well. Let’s define that cupping as a therapy at ancient form of therapy, where a therapist puts special cups on your skin or a patient skin to create suction.

That suction is to help with circulation, for pain, inflammation, blood flow, and so forth. And of course has become very popular. You’re seeing it all over. Let’s talk about, we know what it’s good for it. How do we use it? But can we get paid for it? Let’s talk about cutting more to define it more clearly.

What I’ve been able to research is that there’s about 10 different types of cupping, and I’m sure some of you might say, oh no, I think there’s five. This is just what I was able to research. And it shows you can have things that they call weaker, like cupping medium or. Moving cupping. I see that commonly needle cupping using moxa or needles with it empty or flash cupping, full bleeding, cupping.

You got to remember that. Is it within your scope for your state, but I’ve seen it used with herbs water and realize the cups can be made of several substances. I generally see some type of glass. I seen some very heavy plastic metals I’ve even heard. I’ve never seen it. I’ve even heard of bamboo.

And that kind of makes sense. What we want to focus on. How do we bill for it? Is there a CPT code that we can use that says it? The first thing we have to remember is whenever you select a code, and this is something that you must always do, you must select a code that accurately describes the service.

Not has to accurately do not be creative. Don’t select a code because it’s like it, like my example, if you were to use. Would you be able to code that as acupuncture? Just because you put seeds on a point, doesn’t make it acupuncture because it’s not needle. So it can’t be it’s gotta be all the way.

So don’t be creative with what you describe, do not select the code that climate is close. Always has to be exact. And within that. If there’s no code for it, there is a code, always. There’s a code called the unlisted code and it can be a modality or a procedure. So whenever you have any service and we’re talking cupping today that doesn’t have a code, that’s going to be the more likely code to use, but let’s take a look at is their way of coding.

It’s I’m going to show you something. I deal with a lot, which is dealing with audits. Many of you are insured with American acupuncture council. And remember if you’re audited who’s there. Remember, if you have American acupuncture council of malpractice, they’re going to help you with audits depending on your policy, anywhere from 30,000 to $50,000 a defense.

And this was one of the cases we had here was an office that had issues with coding. And you’ll take a look. I highlighted in blue. So here it says on 52 claim lines, manual therapy was identified as. In the medical records and reporting of the code 9 71, 4 0 is not appropriate using for the Madame for the modality to indicate as cupping.

So I want to make clear, some people will say Sam, I’m putting the cups on manually and I’m moving them around. So it makes it manual therapy. Nope. That would not make it manual therapy. It’s. And though you’re doing it manually, it doesn’t make it manual therapy. So again, be very careful and you hear a lot of people say, oh, sure.

When I use a cup, Nope, that would not be correct. And I want to make sure you can see this. This is directly from. And again, very clear that it’s not to be used for it. So is there a code for cupping? So if you start thinking of all the codes, infrared heat. Okay. Hot packs, electric stem.

You’ll notice there is no code for cupping. So we want to talk about how to do it. And frankly, let’s be clear. Is it really even a covered service? And I think that’s what I want to focus more on. How do you get. And to get paid for it by insurance. That’s what we have to have a code, but is it a covered service?

Take a look here. This is the VA and I’m sure you’re all familiar with VA claims. The VA is one insurance that will indeed pay for cupping 100%. You’ll notice here and I highlighted it where they indicate the services that can be provided along with your acupuncture. And clearly. Cupping, along with other things, but cupping is there.

So a lot of people look at the codes that are allowed under the VA. And I’ll give you the list here. Here’s the codes that the VA pays for an acupuncturist. Notice it was updated for this year. And you’ll notice that code. I put the blue arrows it’s 9, 7 0 1 6. Now I would say in theory, I think the VA is saying you could use that code.

I don’t think it’s quite correct, but let’s talk about. Should you use it? 9, 7 0 1 6 indicates something that’s called a Vasos nomadic device. And the indication for it is to reduction of a deem after acute injury lymphedema and the use of a pop. So I want to highlight you see this little, long kind of blood pressure cuff goes over the area.

That’s what a visa nomadic devices. It’s a large pressure device that goes over an extremity or part of the body that gets pumped. To prevent a DEMA post-surgical maybe prevent blood clots. It might have vibration to promote circulation and deal with lymphedema. Now I’ve had some people argue that well, could a cup be listed under that?

I would say I can see the argument, but I think this goes against the rule. It has to either fit it or not. I don’t think this would fit it. So I don’t think this is the best choice. And I also don’t think it’s the best choice, because if you use it, I will say the VA will pay it. But the VA Medicare rate is 12 to 1400.

It has a relative value of 0.35, which means it’s about 25% of the value of acupuncture. So again, not a very expensive code, 12 bucks now that’s better than zero, but is that potentially the best code? So remember an application modality, one area Vaser pneumatic says devices that provide external pumping forces to soft tissues to the lower and upper extremities.

And I would say trunk as well. So you would say with cupping, could it fit that definition? I could see you dovetailing it, but I still will stay. It is not the best. Cupping is very popular. You’re seeing it amongst sports and athletes and my goodness, the rock has even had it. And I love what he does because he has moons of followers that if he’s getting cut, the more people are likely to try.

Do I see even the person’s left, had a lot of cups place it’s really popular. It really has efficacy. I’m seeing a lot of additional practitioners from chiropractors to physical therapists that are doing it. So how do we. I mentioned the visa nomadic device. And I said visa, nomadic. I think you can argue it for the VA.

I would never use it outside the VA, but for the VA you could. But I think from a monetary point of view, you’re losing money because it doesn’t pay as well. Using 9 7 0 1 6 will literally get you paid less than 50% of what you would be paid. Otherwise when you use what’s called the unlisted modality code.

Now I want to go back for a second and I’ll go back here and show you. You’ll notice those codes are like, 9 7 0 3 9 and 9 7 1 1 3 9. So you can see they’re all on the list for the VA. In addition tonight 7 0 1 6, but those codes do not have a Medicare value, which means when there’s no value purported by Medicare, they pay at usual and customers.

So what I’m saying to you is simply. If you’re billing, even the VA for cupping, what is the best code to use? It’s going to be the enlist of modality. Whether you want to say it’s unattended or attended. Now here’s the difference. 9 7 0 3 9 says unlisted, modality and modality in this way means something.

You apply to a patient, but you don’t have to be there. Like I know when I’ve had cupping, they placed the. And they leave them there for a bit. I would say that’s an unattended, probably appropriate code, but I’ve also had cupping where the provider is constantly in attendance adjusting and moving them a bit.

That’s going to be more of a procedure or hands-on. So the more hands-on and that you’re spending time with the patient 9 7 1 3 9 would be the better choice if it’s completely unattended 9 7 0 3 9. The difference, just to give an example, if you bill 9 7 0 1 6. They’ll pay a 12 to $14 bill 9 7 1 3 9. I’m going to say payment is going to be between 30 and 45, depending on your area.

So would you rather get paid 10 or 30 or 40? I would opt with the higher one. So how do we code this though, to make sure they know what’s coming says it says unlisted procedure, which means it could be for anything. So you have to indicate cupping on the 15th. Actually, it’s not hard. You’ve all seen a 1500 for here’s an example.

Notice on this line item, it says 9 7 1 3 9. And then in the pink shaded section, right above it, you simply indicate that tells the insurance it’s cupping. Oh, by the way, what if you’re doing moxibustion how would you do that? Actually the same way you would just indicate moxibustion whether it’s fully active.

Or one that it’s unattended. My point here is that coding for cupping, the best code for you would be the unlisted code and indicated this cupping, the VA will cover it. They will pay for cupping. It’s part of the authorization. They will pay it under 9 7, 0 1 6, but at a third of the price. So I think it’s better to use this one.

Now, what about regular? Do regular plans generally cover cupping. The unfortunate answer is no, I’m not finding any type of consistent payment here and there I’ve seen it, but not enough for me to really say yes, it’s covering out. The more likely places to be covered would be personal injury more than likely.

But outside of that, if you go to, gosh, the Cigna, Aetna, the blues general, they’re going to come back and say, it’s experimental investigation, which doesn’t it. From your standpoint, it’s not effective, but you know how insurance companies are without a double-blind study. We’re not going to cover, explain to the patient.

This cupping services is going to be integral to you getting better. We’re going to apply it. This is why, and what we’re doing. And here is the cost. If you show the value and the patient sees the value, they will pay for it and it will be covered. So don’t be afraid to pass it on because if you’re not willing to pass it onto the patient, why bill and insurance, if you’re going to give it away, So I would say, yes, I don’t want to bill for it.

It takes time. It takes effort and it is effective. Quite frankly, I’ve seen some really good responses with muscle injuries that I’ve never seen with other types of modalities. Now we’ll hacky puncture too, but that cupping is really been something I’ve noticed because of the amount of use I’ve seen has really made things work better for patients.

So make it available. Billing wise, what’s the best. Unlisted therapeutic procedure or modality, identify it as cupping and then simply put your price. And when we’re talking just simply price, you’re far better to bill cupping under the unlisted code to the VA. Cause it’s a little bit worth three times the money.

So keep it simple. You know how everybody makes insurance billing hard. You just have to understand the parameters. And that’s what our program with you is to do and realize I do articles and acupuncture today, and this one date back to 2010 and actually talks about it and why I wanted to bring it up today.

That this question though, a lot recently, and it’s because it’s become popular because of the VA. Here’s the thing. You can have me as your. Don’t be afraid to reach out to the network service, because from that I become part of your team where you can call, email me, fax me. However you want to get ahold of me to help you with coding and billing, and frankly get paid my goal to make you better.

I’m your doctor of billing to make your office work better. So go to our side, take a look. I would suggest take a moment to go to our Facebook page AAC. Give us a like there and we always update and put news out. We’re always going to be a resource. The American acupuncture council of course, is your malpractice resource, but will your billing and coding and business to resources as there’s our site, there’s our phone number.

Please reach out to us. Don’t be afraid. My email was at the front end as well. What I’ll say to you all is thank you for the time and next episode, we’re going to have Poney Chiang and again, always go out and be successful. But remember, the success is more about being. Which means being good to your patients, be that person.

And I’ll see you next time. Everyone take care. So what I’d like to do with you today is to talk about coding and billing specifically for cupping. This is one that I get this question a lot is that seminar producer, as well as doing our network services, where people call them with questions.

One of the questions I get is, Hey Sam, how do I code for cupping? Can I get paid? What is the proper code? Let’s really get into that.


CollinsHDAAC05112022 Thumb

Limits to Acupuncture Sets Per Visit



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 Sam Collins, your coding and billing expert for acupuncture and the American Acupuncture Council. With another episode to always make sure that you’re on point and making sure your practice is continuing to thrive and to grow our role with the American Acupuncture Council and my service, the network is to always help.

Be the best it can be in implementing the care for your patients and ultimately being paid. One of the things that comes up and I’ve had this question quite a bit from members is there some sort of limit to the amount of acupuncture I may provide someone and that’s a question, certainly some people think do what can I only do two, can I do four?

What is my protocol? Is there some sort of. That I must follow and in a way, yes, but in a way, no. So let’s talk about that. Let’s go to the slides. Let’s talk about what’s going do the type of acupuncture you’re gonna do and what are the limits. So from here, you can see just my basic information, there’s our website, my email address for those that need some extra help, but let’s talk about the care of.

Let’s talk about what is reasonable or what is necessary and what I’d say that always comes back to as a medical necessity. So I’d say the limits to acupuncture more than anything is going to be, what does the patient need? What does it medically necessary? Let’s define that here’s a statement from Cigna Insurance specifically on their acupuncture policy, which by the way, just recently updated.

And it says medical necessity decisions must be based upon patient presentation, including diagnosis severity. And documented clinical findings. So in other words, the more severe the case, obviously the more severe the diagnosis, the more care they might likely need. So you’ll see here, they’re not really putting a limit per se.

What they also indicate is that an individualized treatment, meaning frequency, duration, and so forth is appropriately correlated with the clinical findings. So again, it goes back to severity. So when someone says to me, Sam, is it okay? I do four sets. I’m going to say it can be. But it’s gotta be, is that’s what’s needed it.

I would be careful of a being something that’s based on my style that everyone gets four sets, no matter what. It should be based on what the patient needs. Let’s give one more. Let’s take a look at what Aetna says, and this is Aetna’s clinical policy bulletin, which has also just been republished again, but for 2022, and it says this acupuncture services are considered medically necessary.

Only if there is a reasonable expectation that acupuncture will achieve measurable improvement in the patient’s condition and is reasonable for a predictable period of time. In other words, we’re showing we’re making the patient better. So I’m trying to highlight here is that. They don’t really give a definitive that you can or cannot do whatever is necessary.

In other words, could some patients get better with two, maybe three or even four? Here’s something that came out and we’ve had a lot of offices gotten letters like this. Here’s one from the company empire, which is out of New York, but this is an Anthem company. And we’ve seen this across the U S of course I teach seminars all over and you’ll see here at.

The review indicated your average utilization of acupuncture sessions of what hour are greater or what are greater for personal one-on-one time is greater than what we consider the average of providers. So right there, they’re saying, oh, you’re doing an hour. That’s greater than the others. Now you’ll notice it.

Doesn’t say you can’t do it. It just says, because you’re doing more. They’re trying to say why they’re questioning it, but notice what it says here. We are aware of many factors that may impact the coding of your acupuncture services. So they’re indicating if it is with, for I know someone who treats post-surgical, that is her absolute specialty.

That’s all she does is referrals. Post-surgical patients. She goes, Sam, I generally sometimes do two hours. She’s doing six, seven sets on these patients. But when you think. These are post-surgical patients, lots of severe pain. So would that be reasonable? If they were questioning this, you’re going to just have to be able to respond.

It’s reasonable based upon the severity and need. So is there an absolute artificial limit while in some instances there is. You’ve probably seen something, what they call the medically unlikely edits MUE it’s often termed and you’ll see here. This is the United healthcare is promotion of it. I won’t say promotion, but their indication of it.

This is set up on a federal level and it says this, it says in accordance with the code descriptions and or the centers of Medicaid, Medicare services, meaning medical. Guidelines that CMS national coding initiative, it says the following are, the service limits are as follows. And you’ll notice the initial set is one.

Of course, how many more sets can you have than the first set? The first set is always one, but notice the additional sets all indicate two. So in other words, the amount of sets per this guideline says there’s going to be three pre-visit. I will tell you a lot of carriers have adopted this. I’ve seen this, not just with, I seen it with Cigna plans as well, where they’re pushing these three set part based on this medically unlikely edit.

Now you might look at this and think, wow. Are they picking on our profession? Not really because every profession, chiropractors, physical therapists have limits just like this. And you’ll notice here, I’ve just given a quick list of common codes. Obviously I put acupuncture, chiropractic notice for acupuncture.

The one. The initial two additional chiropractics, only one. And then you’ll notice certain therapies. Like by example, if we moved down to massage, you’ll notice they allow up to four, meaning once you’ve over one hour, they’re going to say no, and these are kind of artificial limits, but they’re just saying they don’t feel that often.

It would be reasonable to do much more than that. So now the issue becomes, if I’m billing insurance, am I limited to this? In a way, it’s what the insurance may cover. They may only cover that many. Can you do more? So let’s say you’re an out of network provider and the patient has a policy where it only pays for three.

Could you still do four and be paid for four? You could, but not by the insurance company. The insurance company is going to pay three who would pay the. The patient. So you have to be willing to make sure informed the patient. Your plan allows a maximum of three. However, for your case, I believe we need four and here’s the additional charge.

That’s if you’re out of network, here’s the downside. What if you belong to an insurance? So let’s say you belong to United as a provider. You will be limited to three. And if you do a fourth, absolutely. You can do a four. But you will not be paid for it and you can not collect from the patient. Cause remember when you join an insurance, you’re abiding by their rules, which means if they allow three, that’s the maximum that we can do for reimbursement.

If you do more go right ahead. There’s no additional money. So you have to make sure beyond these plans. When you join an insurance, you now will become beholden to these rules. If you don’t belong to the plan, you can tell the patient, this is what your insurance covers. This is what we need. And so therefore you do, what’s medically necessary.

Obviously people want to use insurance and we want to give them the best access, but maybe it doesn’t always cover everything. As we’ve all witnessed. How many of you have been to a doctor and you’ve had to pay substantial money out of pocket or things weren’t covered because your plan didn’t cover.

What do you do? You pay out? Here’s one. This is tri west. Now try west. Remember is on the west coast. Basically Texas and west of Texas that handles the VA. And you’ll notice they follow the same thing, one initial and two followup. So you’re seeing this also for the VA side federal plans obviously, and realize that’s also for Optum, which is part of United.

So to answer directly for some plans, there is a limit of. That’s payable. That doesn’t mean you can’t do more. It just means your limit for payment is three. Which means if you’re in network, you’re stuck with three, but if you’re out of network, can you build a patient for additional you’ll notice the anthems didn’t fall that I’m going to always say, treat what you need to do for your patient.

Treat the patient. Not insurance. Remember insurance is nothing more than an eight and never feel fully trapped into it. You’re going to let someone know here’s what your coverage covers. Here’s what we need to do. Here’s the difference provide what is necessary for your patients. So if you need to do four sets, do four, but if you’re in United health care, you will be limited to three.

So be conscientious of following through and understanding different plans and understand what your rights. In the sense when you’re in network or out of network, remember when you’re out of network, it’s up to you to charge what you feel is reasonable and the patients can choose or not choose to get it.

But bottom line is you are not limited unless you belong to something. When you belong to something like the VA, oh, they can say three are United. And so I will say the medically unlikely edits is there. If you go to a massage there. And they want to do two hours, but the plan only pays for who’s going to pay for the additional hour.

We, as the patient or the patient would, so same idea here. What I want you to take away from this is do what’s medically necessary, do what your patient needs, but just be careful understanding when you belong to a plan, there can be limits. And that limit is three to give you a little history of it.

Pre 2019, it was actually for manual. And three for electro and post 2019, they removed it and went down to three. Now the good news to that is I would suggest that many patients, I know me and myself as a patient, I’ve often not gotten much more than a 30 minute, maybe 45 minute. I’ve never had an hour treatment and I’m not saying anything wrong, but I think most patients can respond.

So we want to treat what’s adequate and be careful if you’re doing an hour. And here would be my question to you. Does the patient really need the hour? Are you just doing extra because you’re not busy enough and I’d sometimes be careful of that. Be careful of having a patient that you overdue, just because you feel like you want to throw everything at it.

Be. Be mindful, be helpful. What’s your patients they’re looking for is a response to care whether it’s going to take 30 minutes or an hour. So don’t put yourself in the realm of limiting, but also bear in mind. What is my cost benefit ratio? And remember, benefits are continuing to increase. Take a look.

And the benefit of 2022, it says Aetna will add acupuncture as a standard benefit in new and renewing commercial health plans in 2022. So everyone who has a commercial Aetna plan will be covered. Now, this doesn’t mean some of the federal ones, but all the commercial ones will cover, which means greater access.

Now will Aetna limits you to three sets? I’ve not seen them. I will say Optum United. But not Anthem and Aetna bear in mind, again, medical necessity. What comes down to, we want patients, we want access, give them the best help and understand do what is medically necessary. We’re always here to help remember the American Acupuncture Council, specifically the Network, not the insurance side.

The network is here to help you. I can become part of your own. Where you can call me, email me, fax me. We even do monthly zoom meetings. Take a look at our site, take a look. It’s very reasonable and as well as always gives you access, have an expert on your staff. Always reach out to us, go to our site. And I’m going to say to all of you.

Thank you. Continue success. Peace. Be with you, my friends catch you next time. Oh, and don’t forget, they’re going to bring it up on the screen. There is another show this Friday, and it’s going to be Michelle Gellis please tune in. We’re always here to help take care of everyone. Seeing that.


CollinsHDAAC04062022 Thumb

How Do You Promote Your Practice?



And let’s focus on what are we doing to promote our practice? What changes have we made? What changes will we make?

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 Sam Collins, your coding and billing expert for Acupuncture and the American Acupuncture Council Network. Giving it another episode to try to always, as we do uplift you uplift the profession. This time, we’re going to go off topic for at least where I generally go, which is going to be coding and billing.

And let’s focus on what are we doing to promote our practice? What changes have we made? What changes will we make? What are we doing to really make sure that we’re getting people to understand what we do, how we do it and how we can help them always think of what is the barrier to care. Some of it is just lack of communication.

And I want you to think of it like this. Think of companies that have went belly up and I’ll think of one that comes to mind, which is the store Sears. Why did they do that? Well, someone at Sears didn’t have enough foresight when Amazon came in and started selling things online. Wasn’t that actually what Sears was, think about that.

What is Sears could adopt and adapt that say, Hey, we do the same thing. Wouldn’t they still be around. So I want to think the same thing about our profession, where we’re going to go, what we’re going to do to promote what we do, make sure people understand because of course acupuncture works well, but until we get more people to try it, it’s never going to be as big as we would like it to be because we obviously want to touch as many people as possible.

So let’s go to the.

Do. And there’s so many ways to think of it, but I want to kind of simplify it a bit. Let’s not make this too complicated. However, I use this to say, how are we perceived? You know, think of these pictures. What do your friends think you do? Your mom thinks you’re inserting a big needle. Western medicine has negative views.

What do people really do? Still take pills, but at the end of the day, look at that. Is that the concept are people that are not seeing a shit understand when they get acupuncture care. Think of how many people you’ve seen, who probably were skeptical before they tried your care. Wasn’t even sure it was going to work.

And then we’re like, oh my God, I can’t believe. Think of how often that miracle happens. When people walk into an acupuncture office, they’ve been to so many places. So how do we make sure to attract more people? I start with, what does the public know about what we do? And I’m saying this generically as our profession, but mostly about ourselves.

So I want you to think of ask your friends, ask your family, if you will, what do I. What do I treat? And I don’t want you to bias them. I want you to literally find out what do they really think about what we do. I want you to have an honest answer because we run in circles among other acupunctures. So we hear this all the time and we think this is out there.

And maybe it’s not asking your family, your parents, just friends. Okay. Acquaintances, people, you just meet casually. I fly. You know, for seminars. And one of the things I learned to strike up a conversation is, Hey, have you ever been to an acupuncturist? And the majority are no. And of course it’s an opportunity though, to discuss what we do, how we do it, and we’ve got to promote that part of it, but I want to know what are they thinking?

And you always want to know. That’s the perception we have, what are we doing to mold that perception make a different, but what I want you to do is really see what’s out there. What do people really understand? What we do, frankly, ask some strangers, see what’s going on. How do they go to the doctor by the way, you know, when they go in and do they pay cash, think of in your own practice, are you a mostly cash practice that can work really well, but think of yourself, do you go in to another doctor and pay cash?

So are you potentially limiting patients? Because we have to know what does the public know about what we do? Does it. Well, what happens if someone does an internet search for acupuncture? What does that say? Well, this is one from the Mayo clinic that talks about and inserts needles to reduce pain. So a lot of people say, well, it’s a pain relief, but is that all that you do?

I think there’s so much more. So what if someone who has fibromyalgia says, oh, I don’t have pain. I have fibromyalgia. I know that may sound counterintuitive. But it is sometimes how people think now on that same website, what they talk about, maybe it’s main to relieve pain, but it does get into things like nausea, vomiting, labor, pain, back pain, but you’ll notice it’s a very stringent on pain.

Now notice it does say menstrual cramps. That’s Mayo clinic. How about house? It says it’s an effective for a variety of conditions, but it’s not for everyone. If you choose an active person discuss with your doctor first, he has a practitioner licensed with proper training. So notice it just gives a vague, well, it treats sorta some stuff.

So again, is that really giving people anything about what we do think of your way? If someone went to your website, what did attract them for the type of condition they have? So let’s take a look. What else can you find on the internet? If you search, what does acupuncture do? The national institutes of health.

Of course, you’ve all seen this nausea, addiction, headache. So this goes a little bit beyond, but here’s one thing I would take a look at. If you’re someone who specializes in treating women with menstrual cramps or medical. Could I find you, if I were to Google acupuncture, treating menopause, would you come up?

Would it come up in the city? Remember internet searches are based on information that’s on your site. If the information is not there, it doesn’t appear. Do you have any type of blogs or newsletters that might give a little bit more what they call it? SEO. So people can get to your site. There’s a lot of things out there, but does it say it for you?

Well, here’s one from a company called Evercore and Evercore is behind the scenes on a lot of Anthem policies, as well as United health care. And you’ll notice here, it lists a lot of things that are way different notice asthma cancer, pain puncture. Might you have something that would promote and say, no, this could be helpful.

I have a couple of doctors in the state of Washington. That’s. They work with a couple of psychologists and psychiatrists, but that’s all they treat by the way it’s paid by insurance. But again, that’s something that they promote because most people would golf. It can treat that. I mean, what if you’re an infertility expert?

What if somebody is looking for that, would they be able to find you, is your, are you telling them what you really do? Let’s look at another carrier. How about American specialty health? And of course, I know everyone has a little bit of problem because they should pay more, but let’s talk about how does American specialty health cover?

Well, they talk about kind of, neuromusculoskeletal kind of what I call the chiropractic end of it. So it talks about headaches, hip pain, neck pain, back pain, and so on. So again, that promotion is there for that, but is it promoting. What, if someone were looking for this, what is it saying? Is this information on your site?

If you take this plan, here’s the conditions that we cover and we can help you. I mean, obviously marketing is done by every company. A RP uses acupuncture to market their product. Take a look. Here’s an ad for them. Medicare will cover here’s another one for a company called clever care. This is a TV.

They’re using acupuncture to cover. Now what about this? It says Medicare advantage. Is there anything that you’ve done? So if someone has Medicare advantage, they know they can come and see you. Is there anything as they pass by Medicare advantage here, take a look at this one. This is the United healthcare one.

And think of the promotion here. They’re literally using you to promote their business, but are we utilizing it to promote ourselves? Can you imagine if you have a zero copay acupuncture visit, do you think that’s very hard for some of the. Probably not now we would have to accept payment in full from these plans, but I’ll tell you they’re about a hundred dollars a visit and they cover much more than you think here’s their acupuncture coverage for this Medicare part C policy.

And you’ll notice that it says acupuncture, routine codes, but not all inclusive. And it’s not only including acupuncture, but what does it include? Therapies, things that you do, whether it’s massage exercise. Uh, myofascial release or manual therapy wash off 20, not so much more. Do people know that we do this?

Can it be something that might attract them? Always think of what is going to attract someone. What is going to make them know that what you can do can help them. Here’s another one from good morning America, where they talked about prescription for wellness and it indicates acupuncture. And. How about something like that on your side to make sure people know, okay, we do herbs.

Someone may be looking for that, tell them what do you do, herbs for? What can help? How does it help? And I’m not saying write some long drawn out article, but there’s a little bit of information that at least is introductory. So someone can go, oh, I think I want to try that. So here’s what I want you to do.

If you’re thinking of marketing, what do you mean. Start thinking, what is my thing that I do? How do I know people are going to find me if I do it? So here’s a couple of interesting offices that I think has done something in a positive way. The one on the left is an acupuncture office that they’re in a medical building.

And when you walk by their office, this is the sign. And look at all the things she’s talking about. Fatigue, stress, tension, anxiety. When someone’s walking by. They treat anxiety, they treat arthritis and notice it. Doesn’t just say pain. Now. Pain is many times the origin of most of these, but people often think, well, no, I have fibromyalgia.

I have TMJ. We want to let them know. Yes, we can treat it. Notice that even talks about veteran’s benefits. Look at the one on the right chronic pain, neck and shoulder stress, depression, insomnia tendonitis, Bell’s palsy, nasal analogies, weight control PMs. You want to think of who am I attracting? If you do a lot of sports medicine, guess what you should be talking about?

I do sports medicine. There, isn’t a professional team. That’s a professional sports team that doesn’t use and promote acupuncture. I know several acupuncturist who work directly with the teams and that’s their whole job. But again, are we promoting that this P do people know that they can come to us for it?

Often think of if someone says, what does acupuncture going to do for me? They may not. Because they’re going to have a condition that they’ve never heard, it’s going to be helpful. So I want you to thinking, when a person sees your website or your office, what do they see? What do they know? Will you be able to help them?

So what does it say? Does it talk about you where you went to school? Does it talk about your philosophy? Does it talk about the conditions? Would I be more important is a little bit of that. What have been some of your success stories of people you’ve helped? How you’ve helped them change? Think of that someone searching, like, if you think of it, if you did a Google search in your area and said acupuncture for menopause, would there be anything from your office that will come up?

If you put information like that on your website, guess what Google does. They pull that information and then that’s how someone would be directed to it. I want you to think, how does it attract. What is someone looking for? And remember, it’s not something that you need to write a lot, but something that’s going to go.

Oh, okay. Cause think of most ads don’t take that long. Does it really communicate to their needs? I mean, think of what is your specialty? What are the things that you treat? I have an office. He does only infertility. So I guess what’s prominent on it’s infancy. And he’s very busy because he’s had good success.

Everyone wants to come in because if you have a 50% increase and people getting pregnant, who doesn’t want to spend that extra money considering they’re spending 20,000, all, all the other things. So think of it this way. What is the barrier? I think one of the barriers of care is just people not knowing, but it’s often fear.

So is there anything on your site that talks about the gentle approach and that you won’t feel anything? Think the other barrier can help you. What does communicating to the patient about how it helps them kind of put it from the patient’s standpoint, if you were looking, would, you know, what’s helpful and of course, money, I think that’s often the biggest barrier.

So you want to start to think of, are there things that you’ve done on your site to show people you make it affordable? I always use cars as a way of showing you how we make things look before. When you see some of these fancy car commercials, particularly the mercury with Matthew McConaughey, do you know, they never tell you that car actually costs $80,000, because if they told you that you’d never want to buy it, but if they say, oh, you can lease it for 4 99, that seems affordable.

So also think of, are you having anything in there that helps the patient understand? Do you offer payment plans? Do you offer any other types of discounts do even take insurance and I’m not saying you have to, but you got to think of this. Someone has insured. And they want to come to you what they know.

So for instance, when you belong to any insurance or you accept insurance, I would certainly want to put it on my side. I want people to know, yes, we do take blue cross blue shield or Aetna. And I’m not saying you have to, but you got to think of if someone’s looking, how are they going to find us? And that leads me to something that the American physical therapy association talked about last year.

Now, as a seminar person, I teach seminars not only to acupuncturist, but to chiropractors, physical therapists and medical. And at one of the programs, and one of the things that the American physical therapy association literally said was this many of us look at the way chiropractors have branded themselves in the last few decades and feel a twinge of resentment.

Why can’t that be us? So think of it for a moment. Do chiropractors do a lot of marketing? Do they let people know if you’re in a car accident, you can see me. By example, if you treat the auto injuries, does anyone know you treat them? If you treat VA patients, does anyone know. Is there any way for you to find that out if I look at your site, because if I’m looking and I can’t find it.

It doesn’t mean anything to me, I’m going to move elsewhere. So realize that even these professional associations are beginning to realize that they have to do more, to do their own branding acupuncture. Let’s take control of the message. Let’s take control to put out there whether or not this stuff is covered by insurance.

I do not care because is there a value to what you do? Remember something my mom always said is this people buy what they want. And beg for what they need. Acupuncture is something people want not necessarily needed. And I hope you notice with the connotation. I mean, something that they value they’ll do think of how many people go, oh, I gotta pay that bill.

But what I really want these shoes in a way, that’s what we want to be. Someone who I know there’s enough value there. And trust me, the value can be high. What if someone’s had migraines taking medication that’s not helping. And they come in for a handful of visits to. And they’re gone. Is any of that information somewhere for people to see you allow the patient to do a testimonial?

I certainly would think of it. There’s a great opportunity here that I think all of us haven’t really taken heat of. You have control. Think of how much easier it is with the way you can market now with internet based. Forget Facebook. No, one’s looking at that anymore. Even Instagram too short. I mean, Tik TOK, forget it.

It’s just simply your site. People are doing searches. Are there any acupuncturist in this area that treats what I have or takes my insurance. So I want you to think of who are these patients going to be? If you have a mostly cash practice, talk about it, tell them why you do it. You’re making it affordable.

What if you offer pro pays or prepays? And then of course you have all these insurances. So in my opinion, there’s 12 ways to get. And I want to highlight a few of these. I mean, if you’re treating personal injury, workers’ comp VA Medicare parts seen. It’s why I bolded and underlined I’m in a Medicare part C policy.

It can be fantastic if you didn’t watch last month’s show with me, take a look. There’s some great opportunities. Here’s the thing. You need people that need your care and watch your care. And that’s where your practice will grow. Because one thing that I can always say is acupuncture does really work very well.

Once someone is. But what’s that barrier. Do I know that you can help me? How do I pay for it? That’s what mostly people are thinking. So we want to make sure we set ourselves up that yes, this is how you can come to us. Here’s how we can help. You always know there’s ways of promoting that. Like even on our website, the American acupuncture council network, here’s something last month we talked about Aetna.

Now has all of their commercial plans, not necessarily federal, but all commercial plans now have acupuncture benefits. Wow. What if you’re in the state of Massachusetts that you don’t even need to have a diagnosis? You can treat anything under their plan and there’s 12 visits. But what I want to know is does anyone know that besides you take a good look at how you’ve marketed and branded yourself when you meet someone, do they know you’re an acupoint.

Do they see someone that’s a professional, trust me, getting out in the public, having people know you is one of the best ways for people to come in because it’s people they trust and bottom line people, they help. So think of it. What have I done? Create a plan. Start to put a few things out and track what attracted people when they come in how’d you find me, then you’re going to start to learn what works.

Remember every business does that. Don’t be serious. They’re going to be people who promote and do better than others. Why? Because they have taken some, I guess, old fashioned put the nose to the grindstone and just tried some things, maybe what works for you is not for someone else, but there’s always something.

What I want to say to you is acupuncture has a great opportunity. The access that you have now to people and the understanding the growth potential is infinite. Think of addiction. Think of the VA and all the things that are there, but does anyone find you and I’ll leave it with that? What about a VA patient?

If you’re doing VA, if a veteran was looking for someone, what they find you don’t leave it to happen. Hopefully, we’ll take a little bit of this and do a little bit at a time. I’m not saying you have to be perfect, but it’s trial and error. What I’ll say to everyone is get out and help yourself. We’re always here to help you.

The American acupuncture council is your partner. We want to make sure you’re doing well. Anything that you need, if you need help with coding, billing, documentation, medical necessity, you want to verify that your notes are fine. Not getting. Come to us, we offer two services to do that. Just go to our website.

If you need further help go to our website, we’re always going to be there. Don’t be afraid to call or email. I’m going to say to all of you. Thank you very much. Here’s our phone number and information there. Ultimately, we’re here for you now. Pay attention Friday, coming up is the host will be Shelly Goldstein.

I’m going to say until next time everyone. This is Sam Collins, your coding and billing expert. I’m here for you. Go out and be a good acupuncturist..


CollinsHDAAC03092022 Thumb

Getting Paid Directly from Medicare


So I want to talk about Medicare because there are so many things that are confusing or misunderstood or misrepresented…

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.

Billing expert for acupuncture and the American Acupuncture Council network, as well as the American Acupuncture Council Malpractice Insurance. With another time to get with you to update you on what’s going on, what’s changing to make sure your practice is thriving. Remember the American Acupuncture Council was always your partner.

If you have a question and need an answer, trust me, we’re there for you. So what are we going to talk about? Medicare. So let’s go to the slot. So I want to talk about Medicare because there’s so many things that are confusing or misunderstood or misrepresented that I think are going about. And I’m getting so many calls and requests for this, whether it’s people on my network or coming to seminars, what is going on with Medicare?

What does it really cover? And what is the. Differences between Medicare part, B and C who pays me. So I want to make sure there’s a clear understanding. Regular Medicare part B is what you see on the left side here, that standard Medicare card, but you’re going to know a lot of people have something else called Medicare advantage.

And so we want to kind of talk a little bit about that to make sure there’s a really clear understanding of what’s going on because of course you are being in a. With people requesting information or saying, I heard it’s covered. Take a look at some of these ads. The upper left is from a RP where they put out, Hey, Medicare will cover acupuncture for back pain out or regular med take care of patients sees these types of things and thinks, well, I want to get the care because notice even blue cross blue shield has an ad for it.

In addition, here’s another one, indicating a zero acupuncture for 24 visits. And this was a commercial where they literally show acupuncture on the commercial. Realize acupuncture has become a commodity. For these plans because it’s their way of enticing people to get their plan. Ooh, join ours because there’s a benefit.

Now the confusion of course, is what are the differences between this part a and part B and really what is Medicare? Well, who are the Medicare patients? Will Medicare patients, is it going to be people 65? Obviously, at least as long as you’ve paid into Medicare, I think for 10 years you will automatically get Medicare benefits when 65.

But remember Medicare is not just for people over 65. There could be some people who are younger that have a permanent disability and as a consequence are entitled to Medicare. So don’t be surprised when a Medicare patient is younger, but it also could be people with end stage renal disease, probably not ones that we would see, but certainly the.

Now what’s going on with Medicare is understanding the types of Medicare. Now we have standard Medicare part a, which is the one everyone gets it’s hospitalization when you go to the hospital. But the one we’re speaking of is very typical as well. And it’s Medicare part B I’ll call that traditional Medicare.

So this is the original Medicare benefit that covers going to the hostel. Going to a doctor’s office and having a drug benefit. Now, the good news is these people can use it. Anyone within the system, does it matter? The state and Medicare pays its portion and the patient pays 20% of it. So not bad, a good, nice coverage for people who are over 65, for those that don’t remember prior to the implementation of Medicare, many people who are older would literally go bankrupt with any illness.

So this has been something that’s been quite the good, safe. Bottom line though, is what’s going on for acupuncture? That’s what we’re concerned about. So you notice I have it in red here and it says acupuncture is covered, but it says for chronic low back pain, only under direct supervision of a medical provider.

So all of a sudden, well, yeah, But it’s only covered when done under medical supervision. So that makes it somewhat limited. The low back pain of course is limitations for it as well. But nonetheless, the supervision makes it hard. And part of that reason is acupuncturists have not yet become Medicare providers.

We need to get a bill, which we already have one going. That’s going to make acupuncture providers under the social security, social security. To be part of Medicare. So until we get that, we’re going to be stuck with this type of issue of needing the supervision or, or referral, if you will, from a medical provider, that bill is being moved and hopefully we’ll see something in the next couple of years, but this is kind of the cart before the horse.

If you think that Medicare was really going to first do a study of how good acupuncture could be to see if it was working or not, the evidence was so overwhelming, they decided to cover it. The problem. The cart before the horses while they’re covering it. But because acupuncture’s can’t join, Medicare is still had to have some tangential way of getting in, which means under the medical provider, meaning for traditional Medicare part B, it still has to be billed by a provider within Medicare.

And that’s limited to basically medical providers, so that one’s a little more complicated or a little more difficult, but nonetheless, still the late. Let’s talk about though. Also what a lot of you are experiencing and misunderstanding is there’s this second type of Medicare that’s often referred to as a Medicare advantage plan, or also known as a Medicare parts seen.

I know of those letters can be confusing, but I like to think of it as a Medicare advantage plan. What a Medicare advantage plan is a way for a Medicare patient to literally chip trade their Medicare benefits to this point. And then this plan takes over for the benefits and it’s under companies like United healthcare, Aetna, Cigna, all these ones offer them and they have to offer all the same benefits as regular Medicare.

Sometimes it’s actually even cheaper. Which to me is interesting. When you think of it, how is it that we can manage Medicare patients for like 500, 600 a month in premium yet when we buy premiums for someone that’s younger, it’s thousands of dollars. Well, that’s because it’s insurance companies making sure.

Bottom line though, is that these plans have to cover exactly as Medicare does. So in other words, they have to cover the low back pain, just like Medicare to however many of these fines. And you’ll see this in a second. The last bullet offer extra benefits like acupuncture, and these can be built directly by an acupuncturist to the plan without being part of quote unquote.

Now, some of these plans may require you enroll, and I frankly will have no problem with enrolling because it only gets you into the one and gives you access. These can be pretty darn good, but let’s understand the. Traditional Medicare part B regular. Again, acupuncture is a benefit now, but chronic low back pain only, and up to 20 visits a year or so, not bad.

What it says though, is that the there’s 12 visits within 90 days. And assuming the patient improves another eight, the difficulty for us is that an acupuncturist can perform. But it must be supervised by a medical provider. And this could be an M D a D O a PA, an NP or a CNS. And so these are all medical providers that are enrolled in Medicare.

So in other words, you’re working kind of for this person, if you will, it’s not a referral, but something you’re working with because it has to be built by. So to take a look at it, this under this national coverage determination, you’ll see here. It says the most recent is that it will cover for chronic low back pain.

And that is defined as back pain. That’s more than 12 weeks. Now that doesn’t mean like, oh, I’ve had it exactly 12 weeks, but think of how many Medicare patients talk about all my. I’ve had back pain on and off for the last 10 years. Well, by definition, that’s certainly going to be chronic. It certainly can’t be associated with other inflammatory diseases like infections or metastatic cancer, but traditional, as most people get back, pain realized 85 million people a day habit.

That kind of makes sense. It will be covered. Now here’s something interesting. Obviously you’re all aware that back pain codes updated and part of the complications in dealing with this when they update. Medicare published what codes they were going to allow, even though M 54 50 is one of the codes new for back pain under the Medicare guides.

What they indicated is that it’s only going to be M 54 51 for routine progenic or other specified in 54 59. So make sure if you’re billing Medicare, part of the reason if you’re getting denials is you have to update to one of these two codes and bear in mind. There are some payers that have been delaying until April 1st, for some reason, but.

Those are the codes. If it’s back pain, notice the code, doesn’t say, uh, chronic. It’s just the idea. And that’s why M 54 59 is the more likely now it pays up to 12, but notice it says an additional eight sessions will be covered for patients demonstrating improvement. I think that’s fairly straightforward.

Most patients, in fact, getting acupuncture with back pain, almost always improve, obviously. And it’s just as long as that’s there they’ll allow additional eight meeting up to. Now the complication here is this is not a yearly benefit in the way you might think, meaning it starts over in January. It’s a rolling year.

So by example, it says if the first services performed on March 25th, The next service beginning of the new year, can’t be until March 1st of the following year. So they do it as a rolling month. So it’s literally 20 visits with any within any 12 month period, not January to January, but it could be from March to March and so forth.

Now the complications here is that physicians can furnish it. Of course, medical doctor certainly could physician assistance, but they also have to have some additional licensure for accurate. Bottom line is you’ll notice here. It says auxiliary personnel can do it so long as you have a master’s or a doctoral degree for acupuncture, which is going to be all of you.

And therefore you can provide it. Now here’s the problem you’re providing it, but it says here, auxiliary personnel, furnishing acupuncture must also be under the appropriate level of supervision. Now, a lot of people have misinterpreted appropriate level. It’s thinking, oh, it’s just based on a referral.

And they come in the office, unfortunately, not that simple under this rule, that’s under these two regulations I have, here are 4, 10, 26 and 27. You have to be present in the same office. So it means you gotta be in the office with this medical provider when the service is delivered, they bill for it.

But yeah. This can’t be a simple referral, but in the office, this means either you’re in their office working, or maybe they come to your office, realize that a lot of nurse practitioners, CNS and others are traveling. Maybe they come to your office one or two days a week. This might be helpful, but this is certainly a benefit for someone working in a larger medical clinic.

In fact, this might be an opportunity for someone that goes into a medical practice that does geriatric medicine to deal with low back pain and pain management. So certainly something to think of it. But bottom line. You’re going to be working for this medical provider. Now keep in mind, working for them could be under two ways.

It could be as an independent contractor. It also could be as an employee. So either way it is certainly possible. But again, you can see the limitations here. It has to be done directly under supervise. Now you may wonder, well, what does Medicare pay? So what I’ve done is I’ve just put up a few areas of Medicare payments and you all notice this increased about 10% this year.

So a nice little jump for us, of course, that also helps for the VA as well, but notice in all areas, whether I’m using California, Illinois, Florida, Texas, you’ll notice the first set is generally around $40 or higher, maybe up to 45, the additional sets in the 30 range. So I’m just going to round up. 44 first set 30 for additional sets, which means approximately a hundred plus per visit because generally you’re going to do three sets and I’m not saying always, but generally that’s what Medicare loss, that means a hundred dollars a visit that certainly can be pretty good.

We’ll talk more about that, that money part of it towards the end, but I think this is something viable. If you’re getting a hundred percent. This certainly makes a lot of sense. Now it’ll make the most sense when we can directly. Cause now if you’re working with someone, obviously that a hundred dollars per visit has to be split between two.

So therefore it may not be quite that you’re getting that full amount, but again, this is not. So again about 41st set, 30 for additional sets. Now you’ll notice if you’re doing an electroacupuncture it’s more like 50 and 40. So now we’re looking at probably about 130. If you’re doing a electroacupuncture, by the way, these fees also will apply to VA, but also the.

To Medicare advantage, which I’ll demonstrate in just a second, but here’s what you’ve probably all been noticing. The Medicare advantage is an area that I certainly would say you should be looking into. Medicare may have some limits because of the way we can access the patient Medicare managers. Aren’t that complicated.

Here’s what I took literally off of my television, where they are using acupuncture to advertise this plan. And I’ve seen this over and over notice here. Zero copay. In other words, a patient comes in and they pay nothing. Now with these types of plans, you’re generally going to have to be in network and, or be a deemed provider, which I’ll explain in a moment.

But bottom line is these are going to pay approximately the same and in many instances more, which is not bad. So when a patient has a Medicare advantage plan, this is what you’ll see. They won’t have that traditional Medicare card, but one like this and you’ll notice it literally will say. Medicare advantage right on the card or Medicare part C.

So that’s how you’ll know. Be careful though, the person will still have their old Medicare card. So always ask them, let me have all of your Medicare and all of your insurance cards so you can verify. Cause once they have this plan, they no longer actually have traditional Medicare. They have this plan they’ve traded for it.

And to give you the numbers, there’s about 63 million people with Medicare. That’s a lot. And about half of them now have Medicare advantage plans simply because the benefits with them are often a little bit better, less out of pocket. And yet what’s interesting. How has it, can Medicare advantage plans offer so much?

Yeah, it’s from a plan that Medicare is paying them 600 a month. And again, I go back to, it shows how much insurance companies profit off of others, if they could take the sickest people. So here’s an actual card for a Medicare advantage plan. And this is one that was sent to me. A member of the network was saying, Hey Sam, what does it mean in this Medicare advantage of place?

The Medicare limiting charges, and often that’s misunderstood because acupuncturist aren’t part of Medicare. So you’ve never heard the term limiting charge. Medicare has fees that are called par non-par. The limiting charge is literally 15% higher than the regular rate. So you remember those fees, I just showed you add 15% to that.

So let’s talk now, probably with these closer to $50 for first set. So I want to make sure when you’re billing these Medicare advantage plans, don’t build what you think they’re going to cover bill your normal fee, bill, your 60 or 70. If they allow 50, they’ll pay it. But if you bill thinking, they’re only going to pay you 42.

And you go 42. Well, sure. They’re going to pay you 42, but what if they would’ve been paying you 50? So always bill your regular rate, just know that you cannot collect the difference. And this is what brings up this term deemed provider. Many times when you get into these plans, you may have to join, but often you’ve done.

All you have to do is accept the patient. But when you do accept the patient, it’s like you become in network on a claim by claim basis. In other words, we call it deemed D E M Dean to provider. And what this refers to is this, when you take the patient, then you have to accept what the plan allows. For your billing.

So in other words, if there’s a zero copay, the patient has a zero co-pay except the plant, or if there’s a small copay. Now these benefits actually are pretty darn good. As you can tell what the limiting charge add 15% to what I just said, and you can go, wow, wait a minute. Now, Sam, are you meaning $115 just for acupuncture?

Yeah, that’s exactly what I mean. Now these advantage plans are pretty good and advantage plan has to do exactly the same. As regular Medicare. So it has to cover just like it does here. What is covered the chronic back pain. But most of these plans you’ll notice here. It says acupuncture routine. You can find a net that you can find a network care provider, you know, searching for the acupuncture benefits, online directory.

So what are they looking for? This routine acupuncture. What is routine acupuncture? Routine acupuncture means they cover for pain management, no need for a referral or anything. Notice regular Medicare says they may require a referral or working directly. So I had someone last week contact me and say, Hey Sam, I heard they’re going to implement a referral.

No, no, no, no. For regular Medicare. Cause you have to be under super. But for these plans, you don’t require referrals for routine acupuncture, which means basically pain management, the same you’ll build any United health care plan to illustrate that. Take a look at how they cover it. This is the Medicare advantage plan for acupuncture.

Notice it actually covers dry needling. If you choose to do that, now I’m going to suspect, do acupuncture because that’s what you are. It pays. In addition, you can’t combine dry needling with acupuncture anyway, but notice what they cover here. It’s noting routine acupuncture codes, not a complete list. So what I want to highlight Medicare advantage plans, cover acupuncture, but also covered.

Exams and therapies, because notice it’s not a complete list. It lists the ENM codes and acupuncture codes, and then notice therapies, electric stem, infrared ultrasound exercise. It could include massage and manual therapy always think of what is within your scope. And they will. I have some offices doing some very aggressive care with this.

And while I think it’s a lot for one visit, I have one office that bills well close to $400 per visit. And he literally gets paid almost all of it under this type of plan. Now these are patients that a lot of pain and a lot of things going on, but again, pretty good. So a Medicare advantage plan is something I would probably say I’d want to be part of, because look at the access that they have, the key.

Do people know that you’re willing to take these plans? Are they aware of it? Have you joined any of them? Because to me there’s no downside. If you join a Medicare advantage plan, is there any cost? No. If you join a Medicare advantage plan, does that mean you have to join the regular plans with them?

Generally not. You can join just for Medicare advantage, which means the only downside is you join and you don’t get a patient, but assuming you get one or two more people are looking for a thing of how many people have pain over age 65. I mean, that’s almost a given for many, let’s learn to manage that so that they can start to do it without medication.

So I want to make sure you always are up to date. The American Acupuncture Council Network is always updating information. If you’re not familiar with our website, please go to our website. It’s AAC info network, nothing insurance, but info network. And you’ll notice here we put out newsletters. And one of the things we just put out Aetna is.

Acupuncture to all of their commercial plans now. So that’s a really good benefit, but how would you be aware of it without going to our new section? We want to make sure you’re always up to date. So anytime something’s changing, we’re the resource. Just go to our new section. There’s no cost for it. Just go to the new section and click on it.

Take a look once a week, sign up for our email alert and you’ll get that as well. We also posted out on our social media, in addition though, notice here about how to deal with financial agreements. Remember we did the no surprise, not that long ago. So we’re going to be a resource. Allow me to be part of your practice.

We have a hotline service where you can call me, email me, fax me on any type of information you need questions with. We’re here to help you get paid. We have a vested interest. We want your success. I do because I really want to, before I retire, making sure acupuncture is fully integrated into Medicare.

So take a look at our hotline and we’re always going to be a resource with you. The American Acupuncture Council Network, go to our site. Give us a call. We’re here. I’m going to say, thank you everyone very much. We’re going to have a special Friday show and the guests, the guest hosts will be Shelly Goldstein.

And I’m gonna say to all of you be well, take care of yourself. Remember you’re important, but it’s more important to be good. Thanks everyone.


CollinsHDAAC12082021 Thumb

New Year, New Fees?



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 Sam Collins, your coding and billing expert for acupuncture, the American Acupuncture Council. And of course for you giving you another episode with, to the point from the American Acupuncture Council and malpractice carrier on keeping you up to date, what’s changing. What’s new as the coding and billing expert always want to make.

You’re on top of everything that’s going on and what the changes are going to be for next year. So let’s get started with understanding fees. So let’s go to the slides, what I want to make sure there’s a good understanding of is how do I determine fees? And so you’re going to see what I have here, the RVU update, which stands for relative value units and how that affects your fee schedule, what changes you can make at the beginning of the.

And how your fees are going to be paid. Well, let’s talk about what are our fees. When you hear this term, you see our, or usual customary and reasonable, what does that mean? Well, it’s the amount that’s paid for medical services based on your geographic area. In other words, what is usually in customarily pay kind of like houses, what’s the usual and customary for your neighborhood.

It’s based on what the houses sell for. So in that sense, that’s usually the fee that’s charged for a doctor for a service and falls within the rains that others charge within the area. It is a service deemed necessary to their current condition. But what is the usual fee? Now keep in mind that usual fee has some variances.

Are you on the upper end or Lauren? I hope that we’re somewhere in the middle because here’s my concern. Let’s say you’re charging $50 for a service. That someone, including insurance companies are willing to pay $75 for if you’re only billing it at 50, of course, what are they going to pay you 50, even though they would pay at 75.

So I want to give you some tools that help you to establish a better way of understanding your fee. What let’s understand, what is the model we deal with? There’s a course in the insurance model. And that’s the reasonable customer feed that insurance has say are the acceptable range. And of course there’s a lot of variation to that.

And of course, as you can expect, if you belong to an insurance, like say you joined blue cross or blue shield or Ash, that’s going to be a set fee, which is probably not usual and customary, but the trade-off is I joined. And hopefully you get more patients, but you take far less money, not something we’re really that tickled with and less volume can be there.

So I look at it more from the patient value. What is the service worth that a patient is willing to pay for? And this is where we have to provide the value of the service. So someone’s willing to pay. And I think this is the model that acupuncture really thrives in the American physical therapy association has indicated that they find that as soon as people have a $30.

They start losing about a third of their patients. Do you know that’s not true for acupuncturists? So I’m always a little nervous that we sometimes undercharged for what we’re doing, because we’re afraid of that amount being something that’s going to scare the patient off, but what you have to think of, what’s the value and want you to think of as an acupuncturist, think of the value for a moment.

How many of you have been to a medical. And when you went in, you’re in pain and when you left, you felt better. And I’m not saying this as a negative in a way against medical doctors, but that’s not the way they treat. Think of how many times you have a patient come in. Maybe they have a headache or back pain, and they’re not even sure acupuncture is going to work.

But then after the visit, they’re like, oh my God, I can’t believe I’m not in pain. I’m 50% better than. There’s a lot of value there. So I want us to start to think of the value of the service and how we establish rates and using something called the relative value units. The relative value unit is a value determined actually by the federal government on the cost of each medical service.

Every CPT code has a relative value. Now what this relative value does, it allows you to compare the value of one service to another. So by example, if there’s a service that has a value of one. And another service that has a value of two. That would mean that service that’s a value of two would be twice the cost.

And so one of the things I want to do with this is take the RV use to help us begin, to establish a reasonable fee for the services we provide. The development of this started way back in the eighties and Harvard, and it continues to be updated every year by CMS. In fact, it is updated already for 2022, and I’ll give you a preview of that coming up.

So here’s what I’d like. You all to do. Take a moment. And tell me, what is your fee for these four codes now, obviously you don’t have to tell me, but I’d like you to think or write them down. What do I charge for the first set of manual acupuncture? What’s my fee for the second set or additional set. How about a mid-level new patient exam?

What do you charge for that? And then what do you charge for massage? What I’m trying to point out is if I can tell you the value of any one of these servers. Based on the relative value. I can tell you what the value is for another. In fact, that’s how insurance companies decide to pay for certain services is based on the relative value of each.

So let’s take a look at what is relative value. You’re going to see here a whole page of relative values. And I put all the common codes. If you’ve been to a seminar with me, you’ve seen this, but this is the update for 2020. What you’ll see immediately is that there’s been an increase. If you notice that I put the arrow around it, you’ll notice the relative value for now.

4 9, 7, 8 1 0 is 1.16. Whereas last year was 1.06. That’s about a 10% increase. So if someone says to you, Hey, acupuncturists are having an increase in fees. Actually that’s true. And it’s based on the relative values have been increased relative value though, just compare one service to the other. So the easiest way to think of this is if you look at the relative value of 9, 7, 8, 1 0, you notice as a value of 1.16, and then the value of 9, 7, 8 1 0 is 0.87.

Now, when you look at that, you’ll go, what does that mean, Sam? Well, I’ll make it real simple this way. What if you charge and again, this may be a little high. What if you. $116 for your first set. What would be the price of the second set? $87. That’s the idea. So if you can tell me what you charge for one code, and if that code is accepted and paid by a payer, I can tell you what they’re going to pay for everything else.

Now, the good news is you don’t really have to look at that many codes. I know this list is a little. But I want you to think of what services are you billing on a regular basis? That’s all we need to look at. Don’t worry about all of them. So how would I do this? You’re going to see her on the right. I did some calculations.

Now don’t be put off by the math part of this. It’s not complicated. All you have to do is tell me, what do you charge for 9 7, 8 1 0. So now I want you all to think of that. I asked you a moment ago. What do you charge for 9, 7, 8. You’ll notice I put a charge of 65. Now you might say, well, Sam, how’d you come up with 65.

I’m just saying that’s a typical fee for a lot of acupuncturist for the first set. So let’s just say 65 was your fear is your fee to figure out the fee for every other service you don’t guess and go, well, I guess I’ll charge $10 less. Here’s what we do. We take our. And we divide it by the services relative value.

So you’ll notice that I take 65 divided by 1.16, and it gives me 56 0 3. Now 5,603 is actually not the price of something. It’s the conversion. I then take that number and take any other codes relative value. Multiply to tell me the fee of that service. So by example, you’ll notice here 9, 7, 8 1 1 has a value of 0.8, seven.

So I’d take 56 0 3 times 0.87. It gives me 48 75. So that means if my price for a 9 8 9 7 8 1 0 is 65. What should be my price for a 9 7 8 1 1? Well, I would round up to 49, but I think you get my point that way you make sure you’re not cheating yourself. And I’ve seen a lot of providers do this. They’ll build a first set of 60.

And the second set of 50, 65. Now, of course, that’s your option. You can do that, but he won’t be my concern. What if the insurance company pays you in full for the second set? What does that tell you? You’ve done with the primary code you’re billing way below. So I can do this backwards as well. If they allow 65 for the one, one, I do the same calculation the other way, and I do it the same for every service.

So think of it in simplest terms, the difference between the first set and the second set is about 30%. So if your first sets a hundred seconds, that would be 70 or in this case 65 to 48, 75 or 49. Well, the same applies with any of their code. Like you might say, well, what do I charge? Or what should I charge for an exam?

Well, you notice the relative value for 9, 9, 2 0 3 is 3.2. So I take 56 0 3 times 3.29, and it gives me 180 4 33. Now the reality here is if you look at 1.16 to 3.29, it’s not quite three times the amount, but you can see it’s pretty close. So really what you want to think of is that the price of. Exam should be three times the price of your acupuncture service based on the relative value of the service.

Now, how these relative values work, they determined that the amount of work that’s involved with each service, and that includes not only the work involved with the service, but the type of provider, what your malpractice costs are and so forth. So again, 180 4, based on a $65 price or about three times the amount would be pretty reasonable.

Well, what about other services? Have you ever built, you know, let’s say. How would I figure out my price for massage? Well, massage value now is 0.8, eight. So I’d take 56 0 3 times 0.88, and gives me 49 30. What I want to make sure is that my prices for my services match each other. I’ve seen offices, bill out some pretty large amounts for one code at a very low amount for the other code.

And my question is why are you doing. What was the purpose? Now, if you can say to me, well, Sam, I did that because I just don’t want to charge my patients as much. And you have a good reason, I’ll say, okay, because maybe that fits your neighborhood, but if you’re doing it because you don’t know, like by example, what if you charge 50, 65 for the first set and you charge only $30 for massage?

Well, you. But if someone’s willing to pay 65 for a first set based on relative value the exam, or excuse me, the price for massage would be about 50. So start to really go through these coasts and start to see that. And here’s the beauty. It increased for acupuncture. So, I’m not sure you’ve heard this or not yet, but the prices for acupuncture related to rates associated with Medicare rates, or anyone will go up next year.

Now let’s not get too excited. The rate increase is about six to 7%, but that’s well above cost of living. So, yay. Finally, we’ve got an increase. Do you know? No other profession got an increase. If you go through all the fees, actually chiropractors, medical doctors, physical therapists, all got about a three to 4% return.

Acupuncture got a 6% increase. And I think mostly because the relative values are becoming more apparent. So you’ll notice the relative value for 2021 was quite a bit less now, 1 0 6 to 1.16, you think? Well that’s 10%. Oh, no. Because remember that’s again, already up at that level. So again, probably about six or 7% to give an example of what I’d like you to do though.

Now, if you’ve been to a seminar with me, you’ve seen this RVU sheet and if you’ve never been come to a seminar or join our network, so you can get this type of information, but here’s what I’d like you to do. You don’t need to do every code, but start coming up with a competent, reasonable fee schedule.

Cause I don’t want you to. But I certainly don’t want you to undercharge. And what I find for most offices, frankly, you bill about five or six services regularly. And I would say the average acupuncturist has three to four of those that have the wrong value, which means 50% or more of the code you bill are undervalued, which means you’re just losing 50% of your income.

So what I’d like you to do is go through, do this for your ENM codes and not every code you don’t bill, all of them, acupuncture codes, probably heat like infrared or other ones. Bodyworker massage, pretty typical as well. And maybe a little bit of exercise. Now you might say, well, Hey Sam, I do some other services.

Fine. Do those as well, but realize you’re not going to do a bunch of these. And what I would like you to do with this is begin to break down the cost. So here’s an example, and this is just for California, Southern California, specifically for Los Angeles and orange county. Now this is something we do for our network members in seminar attendees every year is we give you the updated.

For Medicare, which of course means the VA. And you’ll notice there’s been an increase notice 9, 7, 8 1 0 last year was $40 and 7 cents. Now it’s 42 67. Now, is that enough to go? Oh my God, we’ve got a lot more money. No, but a 6% increase if you’re generating a hundred thousand dollars a year. Just on acupuncture codes.

That should be an additional 6,000. So you can see here a nice little jump. Now, remember these are just for the California rates. Every state, every county has their own rates. And again, if you’re a network member with me, or if you’re coming to an upcoming seminar, you will have access to all these. So, you know, the rates that way, you’re making sure that you’re getting paid the right amounts, because my concern is, if you build below these rates, what are they.

That rate. So you want to start to understand what is the value of my service, but let’s go beyond that a little bit. Here’s what I’d really like. You all to do, take a moment to create a spreadsheet, like what you’re seeing here. And you’ll notice what I’ve done is I just put some common codes for acupuncture from exams, through acupuncture, massage.

What I do with one column is put the RV use and then maybe the next column might be what’s your time of service discount. Maybe that’s your price for cash, you know, maybe. You know, five or 10% below what you normally bill, but then you have your regular rate, just regular. What I, bill insurance then of course, what I’d like you to do is go through from payers that have paid you in the last six months or a year and put down those amounts.

What does Aetna pay? Blue cross blue shield. Cigna. I guarantee you all have that. One of the things I do with network members is to go through this and say, Hey, look, let’s start creating a competent sheet. The realization. You don’t bill as many codes as you think. So you don’t have to do a lot, but go through that way.

But what if it isn’t a patient comes to you and they ask you because of course the next year we have the no surprise billing. Okay. What does my plan pay? Well, you can go to your chart and go, oh, your plan is going to pay XYZ dollars. And this is going to be your balance. What it also does though. It’s a chance for you to look to go, which of these are good or bad because as your practice begins to go into next year, what is your plan?

To really begin to maximize your office. One of the plans I would do is let’s do a survey of what is the better paying plans that we may deal with and how much are they paying now? By example, Medicare work comp are all standard fees. Most states have standard fees for that. So you can already put that in and at the very least I’d want you doing that.

So here’s an example with RV use. You can do a lot to determine your care. So by example, if you’re in the state of. The work comp rate in Texas, what they do is take this value 61 17 and they multiplied by any RVU. So by example, I can tell you exactly what the fee is for work comp in Texas for 9 7, 8 1 6.

Remember, it’s 1.16. So it’s 16% above this, or roughly close to about 67, maybe $68. Or how about if you’re in the state of Utah? What they do is use a conversion, but two different ones. If it’s an ENM code, they convert with a 56 conversion or 52 for other codes. So realize that the Medicare conversion is roughly $37 plus or minus depending on your county.

So that would be a starting point. And I’ll give an example. What if you’re admitted? If you’re in Michigan, what they do is they just simply take whatever the Medicare rates are and double them when it comes to personal injury. Now, one thing to be concerned with here is if you just double your rates on personal injury, that’s good because personal injury will pay you.

But what if you charge your other patients less? Remember you can have two different fees. So you’ve got to make a decision, even though I can charge double for personal injury. If you’re charging maybe only 1.5, that’s what you’re going to charge for them. What my suggestion is. Probably be at least 1.25 to 1.5 above Medicare rates.

Notice by example, the Medicare rates in for work comp in Michigan, they just take a conversion of 47 66. So this is where using RV use will help you. But take a look at this one. If you have a patient that’s with Boeing and particularly Boeing uses, and they’re employed with Boeing they’re blue cross blue shield, they sent a directive out this year.

What they pay is 175% of. So what if you got 90% of your patients with this plan and you’re billing a hundred percent of Medicare, you’re losing 75% of your money. Now keep in mind, maybe you don’t want to charge 175% because you still have a lot of patients that can’t afford that. So it’s going to balance somewhere, but my concern is, am I setting my fees off of my best insurance or best richest patients?

Or am I sending it off of my port? So I want to be somewhere in the middle there, but what I want more than anything is a competent fee schedule. If someone says, how did you determine your fees? You’re going to say, I use relative values to determine the value of my service. Tell me what an insurance will pay for one code, and I’ll tell you what they’ll pay for any other code, because relative values goes across the board.

As you can see here, by example in California, we’re comp is 1.2. And so simple way of looking Pennsylvania, 113% Florida, 200% for work comp. So lots of changes here that allows you to start to use this as a way to competently set up a fee schedule. And I’m going to suggest it’s the new year. Let’s start looking towards that.

Obviously, if you’re dealing with a VA patient, you’re going to get an automatic raise, but what if you don’t raise your rates? So what if you bill at last year’s rates, what are they going to pay you for next year? So you’ve got to make sure to bill the higher rate or bill your normal rate to make sure you’re getting the maximum amount out of it.

So here’s something I want to make sure everyone’s aware of. Do you know when we posted this, if you’re a member with us, you received an email on this Medicare fees. The deductible acupuncture fees increased six to 7%. Really good notice we posted this a month ago or thereabout. If you’ve not already go to the American acupuncture council network, Facebook.

And take a look at our Facebook page or in our site, just click on the new section. We update you there all types of things. The American acupuncture council wants to be your resource. We want to make sure that your claims get paid, because if you’re not getting. You don’t need our services. So frankly, we’re symbiotic.

We have to do a good job of helping you to make sure you have claims. We also offer a service. We call the network, take a look at our site, come to a seminar, be informed about information that’s coming out for you. Cause if you’re not informed about. You’re probably left behind. Take a look. We’ve got lots of live, meaning in-person seminars, upcoming, but also virtual.

So just pick the date that fits best for you because we have a vested interest in you. We want you to do well. That’s what we always give you this information. So I’m going to say thank you very much. Next week’s hosts are going to be Dr. Jeffrey Grossman. I wish you all a very good new year in a Merry Christmas, but also let’s plan and have a good prosperous 2022 see you next time.


CollinsHDAAC10202021 Thumb

Identify and Use the New ICD10 Updates



So every year when you hear the new codes is started, always remember it begins October 1st. So it’s important to note, am I making sure I have the codes that I’m using? Have there been any types of updates? So let’s move forward and talk about those.

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.

Welcome everyone. This is Sam Collins, the coding and billing expert for acupuncture and the American Acupuncture Council. Give you another episode of our show that keeps you up to date and what’s changing and moving forward. And as of course, I’m sure you’re aware. There has been an update to diagnosis codes. Keep in mind that diagnosis codes don’t update. At first of the year, they actually update October 1st of the year before. So every year when you hear the new codes is started, always remember it begins October 1st. So it’s important to note, am I making sure I have the codes that I’m using? Have there been any types of updates? So let’s move forward and talk about those. Let’s go to the slides. So here’s what we’re going to focus on. What are the 2022 updates, but I’m going to be pretty acupuncture centric. I want to make sure we’re focusing on the things that you code regularly because obviously each year that can be a lot of changes.

So keep in mind, October 1st is the date and it begins for this year with changes to back pain. So that’s really, what’s new, but it’s more than just back pain. And that’s what I want to kind of warn you about now. Probably not as maybe common, but the focus is we want to be certainly acupuncture centric. And as you well know, you’ve seen these updates year to year from 2017 to present every year there’s updates. And it’s confusing in a way, because often you go, well, if they’re changing 1,974 codes, do I need to know all those changes? And in fact, I would say, no, we want to know about the code you bill, the codes that are reimbursed and whether or not those have updates. So each year you’ll see these changes some years makes literally no difference. Other years can be a tremendous difference.

Beginning in 2021. Of course, there were some updates of course, that you had to work for a headache. Now you can think, okay, got headache codes update, but it was only to I’m sure you remember the [inaudible] in our 51 9. Good to note that those codes did update from our 51. And they are both reimbursable, whether you were billing like Aetna or Cigna, all the other payers. So those went right into the protocols of payment. And that to me is the focus. It’s not just knowing the changes, but what codes are payable. And I think that’s a confusing and often frustrating part for acupuncturist is not knowing what codes you get paid for. Well, for this year, there’s been updates where there’s 159 additions, 32 deletions, and you’re thinking, oh my God, what do I need to do? Well, let’s focus on what has changed for this year.

The one that’s very acupuncture specific of course is low back pain, low back pain is the most universally covered condition for acupuncture. In fact, I would say just about any insurance that covers acupuncture will cover for low back pain. So what does low back pain mean? The old code was M 54 5. Now that code is gone. Don’t use that code anymore. And the approximate synonyms for low back pain are all types. It could be acute chronic, whether it’s pregnancy related with radicular, apathy, mechanical, low back pain, you know, simple lumbago loin pain. Now the key here is that you’re just describing the pain. You’re not necessarily describing the causation. And I think that’s where often some acupuncturists get confused. Should it be better to decode like a sprain or a string? Well, potentially depends on the payer, the most ubiquitous and likely covered those to keep it simple, go with just back pain.

So what has been updated while there’s a new code? That’s M 54 50 that says low back pain unspecified. Now I want to keep in mind that this update began October 1st. So don’t be confused if you treated someone in September and you’re sending the claim. Now you’re going to use the old code. If you treated someone October 1st or later, you’re going to use the new code. So keep in mind that type of issue. But bear in mind, I’ve had a few people that go Sam I’ve built out in 54 50 and it came back as invalid. But I want you to bear to keep in mind that that was likely because of the clearing house. It wasn’t the carrier, but the clearinghouse often they’re just not updating their systems often enough. So what does low back pain unspecified really mean? Well, we’ll get into that. There’s another code and 54 51 for, for T progenic meaning related to the spine that looks promising, but we’re going to talk about that more specifics as to whether or not it’s going to fit for a typical acupuncturist.

And how about M 54 59? So here’s the update three new codes for back pain and 54 50 51 and 59. Now you may already be familiar with them, but let’s dig into what each of them mean, unspecified low back pain. And you think what does unspecified mean? It means that there’s a non-specific low back pain defined and not attributed to a specific pathology. Now often in many states, acupuncturists cannot make a quote unquote Western diagnosis or differential. So this might be your safest bet because you’re simply describing it hurts. You’re not differentiating. Why? So in other words, if there were something like pain in the low back related to a sprain or a strain or radicular apathy that potentially could be coded that way. And for like a Cigna insurance, they wouldn’t accept that, but Aetna would not. They’re going to take only the pain code. So it’s kind of knowing your carers, but this would be a good, easy code to indicate just low back pain.

And I would say this is the one that probably represents the change over from what M 54 5 was. I think this would be a safe bet or a safe bet to use, just to describe the plain symptom that you’re not differentiating it, but just that there’s a symptom of pain. Now you may be differentiated into, you know, B syndrome or cheese stagnation, but I’m talking about differentiating from a Western standpoint, like ridiculous apathy. Well, what about M 54 51? Now that’s specifying that there is specific pain from the vertebra or spine. Now I liked this because it seems like, oh goodness, I’m going to say it’s spine related, but let’s understand this really doesn’t, isn’t going to be used very much because the purpose of this code, which wasn’t well-publicized the purpose of it was to describe more specifically, what’s called vertebral endplate pain, which means actually a pathology of the bone that’s causing it.

So I would suggest this is not one you would use for like, oh, it’s something related to the spine, like a sprain strain. You would code that. So M 54 51. I’m not saying it’s not usable, but not very likely unless you have a differential of end plate pain in the vertebra of the low back. So not likely it’ll be a covered diagnosis, but make sure you have some specificity for it. The spine related conditions, such as sprain strain, radicular, apathy would not be appropriate for this. Cause simply code that. And again, I’m going to implore you. Here’s kind of the weirdness, Aetna wants only pain. However, Cigna will allow you to differentiate. So Cigna will accept back pain as well, but they allow you to differentiate to sprains and strains. So depending on the carrier, it may allow it for instance, Anthem would do the same.

Well, what about this other one? It says other low back pain. So we have unspecified and then others. So this is determined to be kind of non-specific low back pain is defined as low back pain, not attributable to a recognizable known pathology while you’re thinking, well, wait a minute. Isn’t that? What other or unspecified mean? Other means, I think you can kind of recognize that there’s some sort of causation, but just not one that you’re directly attributing it to again, pain, but not F not differentiating like spraying string. So the reality is it’s likely that you’re going to be coding M 54 50 or 59 as an acupuncture provider to replace the M 54 5. The key factor is making sure that you’re describing low back pain with the correct code. Keep in mind. They now require five characters. I know some of you are going to say, but standby have built in, has been rejected.

Remember that’s likely from the clearinghouse and potentially what you’ll need to do is just simply wait until they get an update to it. The problem here is that what about some of these plans that have a very short window to send claims? So check with your clearing house to figure out why they’re rejected because the carriers have certainly updated. What’s the best practice for this best practice. Use them 54, 50 or 59, simple 51 again, end play pain. I think gets a little bit, um, outside of probably scope. I’m not saying no, if it’s predetermined, you know, by example you could code are riotous, but it’s not going to be by you directly, but from, you know, their medical provider, they bring in the note. So again, best practice and 54 50 59, well everyone’s onto those codes, but are you aware that there was another code that updated headaches are also universally covered for acupuncture?

And there’s a new code specifically for what’s called a cervicogenic headache. Now cervicogenic means that it starts in the neck. So it’s a neck problem, but the pain is perceived in the head. So a little different from tension, but it’s usually involving some type of range of motion or other issue that’s directed into the neck. Now what’s the reason they’ve added this code is because they wanted to make it somewhat more specific, a cervicogenic headache before this code would have been coated with our 51 9. But now that there’s this specificity you could use code by example, our 51 9 would include things like, uh, I would say probably, uh, a headache where you’re saying it’s a sinus headache or some type of facial pain. Whereas this one is just a bit more specific. Would this be covered for acupuncture providers? Oh, absolutely. Again, you’ll see this one with Cigna.

I believe Aetna will adopt as well, but at this point I would hold off and stick with the R codes until we get a for sure on it. This is something that isn’t going to be a lot better to coach cervicogenic headache compared to say just a headache. Well, I will say it’s a slightly more specific and it might mean why you’re doing other things. Maybe it’s involving some neck pain. I mean, certainly you could have a headache which is playing neck pain, but again, I just liked that there’s some additional codes that you can kind of specify a bit more. I always will say medical necessity often as determined by the complexity of the condition you’re treating. So if we have simple back pain or simple headache, we’re not thinking very severe, not longterm, but in turn, if I said migraine or cervicogenic, there’s a little more severity and chronicity to that same would apply.

Let’s say you have low back pain where there’s radicular apathy. That’s certainly going to be more than simple pain, but again, it’s knowing your carriers, which carrier will and will not accept. And that’s, what’s important to know. That’s one of the reasons we do the service that American acupuncture council, the networking seminar. So make sure you stay on top of not only what the new codes are, but which ones are and are not payable. Well, what also updated now, this is when you’re going to go, well, sing them. This is, you know, I don’t cope, cough. It actually, I’ve not seen cough covered for any carrier though. I’ve seen some that do cover respiratory issues, not all, but some do well. This is a new code for cough, and I’m not sure, obviously that many of you were using these, but they did update them.

The codes now no longer are three characters. They now are four and in dictates the type of cough, but here’s why I’m bringing this up. Could this be a complication? Could this be what we call a comorbidity or adding to the complexity of the patient’s need for care? Let’s say a person has back pain, neck pain, and they’re coughing a lot. Could that irritate that so-called, Valsalva fecal pressure caused that pain to get irritated maybe. And I’m pointing out that these are things like let’s say a patient has a significant cough. Would that be something I want to document as part of their care, as part of their history and indicate anything that might increase the need for care, realize that even American specialty health and these types of carriers, when you’re requesting additional care, they’re not only wanting to know what’s going on with the patient in the sense of the primary reason for care, but all the other potential barriers to the patient responding well.

And that could be things of this nature. So always keep in mind, diagnosis is going to be the lifeblood of payment. It’s what we’re doing, but all plans have a specific code that they allow. Remember Aetna and Cigna are a bit different Evercore, a little bit different, a little bit more ubiquitous, but what about United? And now there’s a lot of similarities, but differences. So make sure you understand the codes that they are allowed. Make sure you’re using the code to the highest level of specificity, which means the new back pain codes have to add a digit, but most important, make sure it’s on their list. By example, if you were to code back pain to both Aetna and Cigna, those would be payable. But if you were to code a sprain of the lower back as 33, 5 XX, a Cigna would pay you, but Aetna would not.

So then how would I code back pain or sprain to Aetna? Well, you got it. If there’s pain well, will a sprain cause pain. Absolutely. So I simply just code the pain. So what’s allowed here is that Cigna, for instance, or Anthem allows a greater specificity in severity, but it still will be covered by sticking with the code. And that’s the part I want you to get. Don’t overcomplicate this, make sure the codes that you’re billing, which you’re probably eight to 10 on a regular basis are accurate. Correct. And up-to-date to make sure that your claims simply can be paid without the right code. We’re going to have a problem. So it’s easy to understand codes update every October 1st. Are there any other codes that have updated? Sure. But how often do you build Sjogren’s syndrome? Have you ever coded that? Probably not. They updated that code, but again, not one we would use regularly.

So I always will say, don’t be afraid to be a little acupuncture centric, just have the right code to note your claims get paid. And that’s really our role. The American acupuncture council is always here to be your help. Not only is it your malpractice carry, but also your support. Remember there are seminars and programs we do to make sure your claims get paid. Like if you’re saying, how do I get that list? Well, that’s where our network services do. And what I would ask all of you to do, take a moment to go to our Facebook page, to the American acupuncture council network, click on our Facebook page. There’s weekly updates on all types of issues, coding this week’s questions on how to do an ENM. And do you need a 25 where there’s also updates regarding vaccines and other types of issues. It’s always going to be a good source for you. So take a look. We always want to be here to help. That’s really our goal and mantra. Your success is our success. So I’m going to say thank you for being with me next week’s guest will be Dr. Taso-Lin Moy, and I’ll look forward to seeing you the next time. I hope to see it a seminar take care of everyone.