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.
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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.