Well, today I’m gonna spend some time talking about valuation and management services or E and M codes or exam codes.

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 you, let’s make sure your claims are getting paid, and I don’t care whether you’re doing cash insurance or otherwise. We always wanna make sure you’re doing well, we have a vested interest in you.

Well, today I’m gonna spend some time talking about Valuation and management services or e and m codes or exam codes. And I’ve recently had a lot of offices with issues of Sam, my exams are being denied or they’re not paid and they’re giving me excuses that don’t appear. Right? So let’s talk about that a little bit.

Does a patient require an exam? Of course they do. Well, let’s get into that. Let’s go to the slides. Let’s talk about what’s going on and getting paid for your e and m services. How do I get paid for my exams? And I use the term exams because. Often people will say e and m, and then they say, office visit.

And I want you to keep in mind an office visit is anything that you do when a patient comes in, they’re visiting your office. So keep in mind, office visit from your standpoint should just be the visit overall. It depends on what you do. So by example, on days you do an exam. That would be an e and m service, and you may do treatment the same as well, so be careful.

The term offices, it will often get you confused. What I’m speaking about for exams of course, are evaluation management or e and m codes. If you’ve all learned, and you’ll notice we have two types. The new patient, the established patient, you know, two oh twos to 2 0 5 for new 2, 1, 1 to 2, 1 5 for establishing.

What are these for, for the indication when the patient required an examination by you. To determine their diagnosis, their need for care, and so forth. And so we’re broken down into four codes for new patients, five for established, and they’re pretty straightforward. They just indicate how much time or how much medical decision making did you spend doing an exam.

You should be familiar with that. That’s not the hard part. Where we run into problems often is, I’ll get off the saying, Sam, I billed for an exam code. And I didn’t get paid. The insurance said it’s not a covered benefit or it’s included in something else. So what is it that’s required to do or get paid for an exam?

Well, let’s think of it. An exam is something that’s absolute required. If an insurance says that you shouldn’t do an exam or it’s not within scope, I can’t believe that not to be true. I mean, obviously when a patient comes in, what’s the first thing you have to do? In order to know whether you can help them, you have to evaluate them.

It’s required to determine the condition and their need for care, what’s wrong with them. And then of course, I would argue it is a ethical and legal requirement. Can you imagine the liability if you said, Hey, I don’t care. What’s wrong with you? Just shut up and lie on the table and start needling in you and go, well, we’ll see what’s happening.

I don’t care what’s wrong. Well, of course not. It is an absolute requirement that you make some level of evaluation, determine the need and necessity for care. So I’m gonna say it is an absolute requirement to do an exam, however, where the confusion comes in is how do you bill for it and how do you document it?

Well, let’s realize the one thing that’s probably the most common issue for acupuncturists being denied for exams. Is the failure to understand that every time you bill an exam code an e and m code with treatment, you have to put a special modifier on it in order to determine and to demonstrate it is separate.

From the exam associated with the treatment. So notice here it talks about the acupuncture services or procedures includes an e and m assessment. So in simplest ways, think of it this way, if you saw someone for the very first time, you are clearly gonna ask them lots of information about who they are, what’s their symptoms, what’s going on, what makes it worse, what makes it better.

In other words, you’re gonna do a pretty detailed history. You’re likely gonna do some physical exam things. Maybe it’s tongue and pulse, maybe palpation, range of motion, you name it, the many things an acupuncturist might provide. And then based on that, you’re going to determine a diagnosis and then begin some treatment.

Well, those things actually are somewhat included in the acupuncture service, but here’s where we have to be unique. Realize the acupuncture service does include . A small exam. Now, the first visit, the one I just described, is clearly different, above and beyond. But let’s talk about that first visit is one thing, but what about when the patient comes the second time?

Maybe I come to you two days later and you say, Hey, Sam, how are you feeling? Is that a little better or worse than last time? How much time did the pain resolve for you? In other words, you’re gonna do a little short exam that includes a little history, maybe some findings such as, you know, uh, tongue and pulse again.

And then begin treatment. So there’s what we call a pre intra and post-service evaluation associated with treatment. So here is the number one reason most acupuncturists are denied for exams. You forgot to tell them this exam is above and beyond what I normally do as part of the visit. It’s a true examination and we have to put modifier 25.

So if you’ve been denied for an exam and you’re not familiar with 25, that’s probably the number one reason that modifier is necessary to indicate to the carrier that this examination was separate and distinct. Therefore payable, no modifier, no money. Now, why is that? Because you’ll see here, there is a pre-service associated with treatment.

When they come in the second time, you’re gonna do a little review of their record, a little record review, face-to-face time with them, do some evaluation things, get them set up for care, perform the care, and even after the care, you’re gonna evaluate, Hey, how are they doing? Give them some recommendations for at home.

And this is why it says specifically in the CPT Manual. It says what you see at the bottom here, it says, additional evaluation and management services may be reported separately if and only if the patient’s condition requires a significantly separate identifiable e and m service above and beyond the usual pre and post service work associated with care.

So in other words, we’re saying, no, no, no. This is not the one that we do day to day, but this is the one above and beyond. So to come full circle with that, when is that necessary? Well, clearly the first visit. There’s no doubt a first visit should be separately paid for an exam and we put a 25 ’cause that’s clearly above and beyond what you would do on a follow-up.

Now, when would it become necessary again? Now, some of you say, well, Sam, I do an exam every day. That’s exactly what we’re pointing out here. You do and we understand that, and a little bit of that is associated with the treatment. Keep in mind, that’s not only true for you as an acupuncturist, that’s true for medical doctors, chiropractors, physical therapists, anyone that’s doing this type of care.

Would have the same provision. So they have to put the modifiers as well to show that it’s separate. So we have to make sure it’s above and beyond. So it says here if and only if it requires a significant one. So the day-to-day one, you do for, you know, several visits after, not really, but when would it be appropriate?

Certainly every 30 days. Now why every 30 days? It’s the standard. It’s the one set up through Medicare that all insurances have adopted. So an exam on the very first visit. When every 30 days absolutely reasonable should be payable. Just remember, assuming there’s treatment, put a 25. Well, what if you say, what if I don’t put a 25?

You won’t get paid. Now, you don’t need a 25 on the day-to-day one, but on the one that’s exam, so the first visit. And then about every 30 days. Now, some of you say, I like to do it every six visits. No, it’s every 30 days. Whether you do 12 visits in 30 days or six, keep in mind it’s about 30 days. Now, there could be instances.

What if the patient says, Hey, last night I fell down and I hurt my back. Would that be appropriate to do a separate exam from what you were seeing them before? Let’s say it were headaches. Well, of course, because there’s something new or significant that’s above and beyond, so make sure it has to stand out.

In other words, make sure the exam clearly shows that this is not the routine exam, and that’s probably the number one reasons things get denied. So simply put, when you’re billing, put a 25, notice this example here. You’ll see 9 9 2 0 3, that mid-level exam. But because there’s acupuncture performed the same day.

We put the 25 modifier on it. The 25 modifier does not change the price. It’s still gonna be paid the same. It just indicates that it’s payable. There is no reduction in doing that. In fact, in many ways. I wonder maybe should that have been the second thing you’ve learned in acupuncture school? I mean, the first thing, of course, how wonderful the profession is, all the things you can do.

But can you imagine how many of you finished school? Never learn this one simple thing. And then of course you get out and you’re frustrated like, how come I don’t get paid for exams? Well, because you didn’t put the proper modifier. Now let’s keep in mind, I’ve had some offices though, that are saying, well, Sam, I know that I’ve been doing that and these insurances still won’t pay.

So what I’ve done here is I’ve taken a page. From the CPT book, I just took a picture of it. Put it up here, and here’s what it says. Notice it says, evaluation and management services may be reported in addition to acupuncture procedures when performed by physician or other healthcare professionals who may report them, which means you.

Now we move down a little bit here and we’ll get into this section here and it says it may be reported separately using modifier 25 so long as it’s above and beyond. So I wanna make sure if you ever get a carrier that’s saying . You shouldn’t be able to. I wanna point out the CPT manual clearly says it.

This is not unique to you. It says it the same for chiros, the same for medical doctors and so forth. So it is absolutely appropriate. However, there are some plans that come back and say, no, we’re still not gonna pay. So let’s talk about how to deal with if it’s denied, was it billed properly? Would be the number one thing.

Did I put modifier 25? That’s probably the simple one, but sometimes you’re gonna say to me, Sam. I did put the modifier 25. It still came back and it stated the exam was included in another service. What you’re gonna do is push back and say, excuse me, this was done on the first visitor every 30 days, and there was clearly a separate and distinct service, an exam that was above the routine day-to-day visit.

So you’re gonna push back on that and basically point out to them it was separate. That’s why we put the 25. But here’s the bigger problem sometimes. It’s because you have a contract. It’s why I will warn you. In fact, how many of you have worked with me directly? one-on-One to know whether or not it’s worth it to join some plans.

I’m not gonna say never, ever, but you wanna make some better choices. ’cause sometimes when you join these plans, you join ’em and think, great, I’m gonna get more patients. Do you know many of your contracts say we don’t cover exams? So the reason it may not be covered, it’s part of your PPO reduction.

It’s basically saying, we’re gonna send you a lot more patients, but we’re not gonna pay for the exam. You have to make it a business decision. Is that worth it to me to get less money, but maybe more patience in some instances? Maybe, but for me, mostly, probably not. So what if the issue is part of your contract?

Is there a way to dispute that? No. That’s the contract you signed up for. Now, maybe you might decide not to be part of it. This is why. Think of it. If you’re just a cash office, isn’t your first visit more expensive than a second visit? Think of that for a moment. Why is that? The first visit has an exam, but here’s the issue we’ve been running into, and I know a lot of you on the East Coast, I’ve done seminars there up and down the East Coast from New York, down to Florida, that the plan says an acupuncture provider is not paid or may not even do an exam.

We’re running into this into New York quite a bit, and my answer to that is, excuse me, you’re saying an acupuncturist cannot perform an exam. Would that not be against. The rules of just engagement of a patient. Can you imagine the liability if a doctor said, oh, I didn’t examine them. I don’t care what’s wrong with them, I just treated them well, how could you treat someone without evaluating what is wrong and knowing what to do?

So there’s a lot of pushback on that. If that’s what you’re running into, please get part of your state association. Join us in fighting to say, excuse me. Of course it is part of your scope. In fact, what I’ll tell you is look at your scope of practice. Does your scope of practice indicate an evaluation?

I’m gonna guarantee it does, at least at some level, so therefore should be payable, so be careful. I think what’s happening is some payers are finding, hey, acupuncturists will just go away if we tell them no, we’ll just pay for treatment. We don’t wanna pay for an exam. My goodness. No. If you’re doing an exam.

It’s necessary. Of course, that’s payable why it takes time. It takes effort to do it, so make sure that you’re always pushing back. However, please be sure if you are billing for an exam, and I don’t care whether it’s cash or insurance. By the way, is there clearly more information and more details that would show this visit had a distinctive exam?

Keep in mind if you’re billing for an exam, there needs to be an exam above and beyond, just kind of like acupuncture, and we’ll talk more about this coming up in the first of the year, but how are you documenting it? How to make sure you’re avoiding anyone coming back, saying the services weren’t properly described.

Not hard, but there’s things you have to do. Have you ever had help with that? Have you ever understood it? Maybe not. That’s what we do with the network. It’s not just about practice and making more money, but making sure we’re compliant. All those factors, I want to help you with that. That’s what we do with the network.

We do the education. Come to a seminar first of the year, you know what’s happening. There’s updates to these e and m codes. Nothing major but enough that you want to be aware of. To know which code to properly choose, and there’s some additional codes that are updating as well. We always want you to be in the know.

The American Acupuncture Council is your partner. I’m your partner. Your success is ours, and I wish you well. We’re always gonna be there as a resource. Take a look at our website, there’s our phone number, come to our seminars. We’re here to help everyone go out and do well, and I wish you a really good New Year and prosperous new year.

Thank you.

Click here for the best Acupuncture Malpractice Insurance?

Get a Quick Quote and See What You Can Save

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.

Greetings, everyone. The coding and billing expert is here. Sam Collins, the American Acupuncture Council is your partner in success. The network is the other step of that. How do we help you? We make sure you’re getting paid for what you’re doing, and I don’t care if it’s insurance, cash or otherwise. One of the things to get updated on, of course, is diagnosis.

Click here for the best Acupuncture Malpractice Insurance?

As you’re well aware, diagnosis actually update every year, but here’s a riddle for you. When do the 2024 diagnosis codes update? You’re thinking, actually they already did diagnosis codes always update on October 1st, the year prior. So really the answer to the riddle is the 2024 diagnosis began October 21st.

Of 2023. What’s important to note though, is yes codes update, but do the codes update that are important to us, meaning the ones that you use regularly. So let’s talk about that. Let’s go to the slides. Let’s talk about what is going on for 2024. In fact, right now, what’s happening with ICD 10? ICD 10 is our coding system.

Get a Quick Quote and See What You Can Save

It’s what we use to communicate what’s wrong with our patients. Now, you might say, SI, I don’t bill insurance. I don’t need to know a code. You better know a diagnosis. Whether you’re putting the code down or the diagnosis, it should be accurate. So by example, if I were to say someone has neck pain, that would be okay.

What’s another way of communicating that, whether it be a super bill or a 1500 claim form is AM 54 2. realize every code is universal. That I don’t care if you’re in China, if you put M 54 2, they know you mean neck pain. So we always have to use coding to make sure we have the best and most appropriate coding for what is wrong with our patient.

Diagnosis matters. It really is. What is wrong with your patient? Now, some of you might say Sam, I can’t diagnose in my state. If that’s true, although I’ll say some of that’s not quite, someone comes in with pain. You can say they have pain. You’re not differentiating it, you’re just saying pain.

But what diagnosis is what’s wrong with the patient? Why are they there? Now, what I love about acupuncture is the simplicity, but the genius of the simplicity of acupuncture. What does the body always communicate when something is wrong? It always tells us one simple thing, I’m hurting. I’m in pain. I don’t care what you have.

Pain is always gonna be part of that, so keep it simple. Pain is gonna be fine. For the most part though, we can go beyond that. That’s not all what man? Acupuncturists treat lots of things. Like by example, if you’re treating with someone under the insurance eviCore, they’ll pay for strokes. They’ll pay for menopause, they’ll pay for anxiety, depression, anorexia.

So there’s a lot more beyond. Acupuncture now is being recognized to do much more than just pain management, though. Pain management is a very popular thing to do. It’s not all that you do. So have to remember when we’re talking about coverage. Coverage for some insurances may be limited to pain. But it can be, go beyond that.

Here’s a couple of offices that just put up signs in front, and here would be a thing I’d have for you is do people know what you do? Like I drive by an office that says acupuncture. Great. So when you just put that up, what are you expecting? That I know Something that no one’s ever taught me. I. You’re hoping.

So here’s two offices that let people know what they treat. Notice this one is fatigue, stress, tension, anxiety, depression, so on it goes all these conditions. The other one even indicating like Bell’s palsy, start to think of, we’ve gotta educate people what you do, regardless of how you’re getting paid, whether cash or otherwise.

We have to tell them what we do. And every one of these things has a diagnosis. So that way, even if you’re in all cash office, can I give them a Super Bowl with a diagnosis to make sure we can potentially get the best possible payment by example? Here’s for Aetna. This is Aetna current. This is gonna change after first of the year a little bit, but right now you can see this is what Aetna covers.

Now what’s really interesting here, you’ll notice it says these are the codes that Aetna covers if the selection criteria is met. But then it says, not all inclusive. You know what that’s really saying? These are the codes we pay for sure. There’s others, but we’re not gonna tell you. But I would say, look at this and start to pick up.

Notice it says Migraines. So it covers migraines, but if you notice, you dropped out other types of headaches as well. Then back pain, hip pain. In other words, I’ll tell you, they cover pain, but more than beyond that. So it’s a matter of knowing do I have the right code? Here’s what’s happening with ICD 10.

We have to know that diagnosis code has to reflect what we’re seeing. I would say the most common codes, pain symptoms and signs, they’re acceptable. Probably the best payable codes often, but we have to know. Wait a minute, Sam, you’re talking about an update. I know. I. So let’s talk about the updates. Every year there’s an update and as noted, the ones change for this year, October 1st.

Now, frankly, I will tell you I’m very acupunc centric when it comes to this. I really don’t care about things that acupuncturists don’t manage, treat or get paid for. So if you told me something about nephrology, I go that may be an issue, but I’m not gonna worry about that change ’cause it’s not a code I’m probably going to be using.

So this year there were a lot of updates. You’re thinking, wow. We have 73,000 diagnosis codes. Think about that. There’s that many conditions. Yep. Now, let’s be mindful though. How many do you commonly do? I’m gonna say most acupunctures probably code 10 to 15 things. And it’s because we see a lot of the same things, or you specialize.

So we have to make sure are the things that I treat changing. So there are 395 additions, 25 deletions. What has changed that I can see that might affect you? Here’s one. Migraine. It was first on the list for notice. Now we have codes that indicate chronic migraine. And I know you might be thinking, Sam, there’s always been a code for a chronic migraine.

No, there hasn’t. There actually has not. There’s been codes for migraines, never identified as chronic. Now, what does chronic.

Chronic mean. Honestly, from a pure coding standpoint, chronic means a condition that is lasting longer than you would expect for it normally to be gone, or probably in simplest terms, 12 weeks. So a person that’s had migraines off and on for 12 weeks or more. It’s probably chronic. In fact, I would make an argument that most people that get migraines, they’re probably recurrent.

So I’m gonna jump in and say maybe most migraines, unless this is the first time the person ever had it, is probably chronic to an extent. What I’m pointing out there is just a way of coding it. Are you paid for migraines? You bet you are. Now, can you code headache? Instead of migraine? No, I guess you could, but I want you to think for a moment.

Let’s talk about insurances like an As, H or others. If you’re requesting 12 visits for headache, I doubt they’re gonna give it to you. They’re gonna think, come on, it’s a regular headache. Treat ’em a few times. But what if you code a chronic migraine? Does that set up something a little different? Think of a person with simple back pain.

That’s how you say it’s back pain. But they actually have . Disc bulging with radiculopathy. That is painful, but is disc. Disc with radiculopathy more serious? That’s a patient probably gonna treat for months. Here’s the idea. Give me the code that best describes what’s going on with the patient. So is this a big deal?

No, but it’s one to add to your arsenal. How many of you have a common code list? How many of you have been to American Acupuncture Council? Our network seminars, we provide you with a list. Of all the codes that are payable by insurance and in fact that list is further divided into which insurances do pay for some, which ones don’t pay for some, a good way to look.

But nonetheless, this is added to the list. They’re definitely covered. What else has changed for this year? Remember last year, not any big changes, but the year before, remember the back pain code change and you had all that back and forth. I’m gonna give you a quick tip. If you are billing a Medicare Advantage plan.

And your coding back pain, which of course that’s what they cover. It must be M 54 51 or M 54 59. Do not ever use M 54 50 for back pain. When it comes to anything related to Medicare, and I’m not talking just regular Medicare Part B, but I’m talking the advantage plans that pay you directly. This year migraine codes changed, but notice this code for Parkinson’s.

You’re thinking, oh, come on Sam, Parkinson’s. I won’t say acupuncture treats Parkinson’s directly, but what do Parkinson’s patients often have? Painful and stiff joints. Back pain. So I would look at this as being a comorbidity. I’m not treating it directly, but a Parkinson with Parkinson’s may have more need for care.

I’m not saying treating Parkinson’s at all, and I’m not saying I’m really worried about this coach, but should you be aware, will a Parkinson’s patients have some different issues if you’re dealing with an ASH and you’re requesting extra visits. These type of comorbidities are actually what they pay attention to that, oh, I see why this person needs a little bit more.

What about osteoporosis? M 54 51 is a code that indicates back pain. That’s vert, progenic. Might a person with vertebral genic or osteoporosis be part of that? Here’s some new codes for that are gonna be related to the pelvis. Now, again, I’m pointing out, you’re going, Sam. Do I really care about these?

Probably not in the sense of directly, but indirectly. Think of you’re treating the human condition. If it’s manifesting with some pain. There’s always a way to do that. What I’m concerned about though is what were the changes this year? Migraine. So if you don’t have an UpToDate list, you may want to get one.

Come to the American Acupuncture Council, the network. If you’re part of our network, if you come to our seminars, you get it if you have malpractice through us. Thank you. Malpractice is separate. If you come to my seminar, it doesn’t give you malpractice coverage, so we wanna make sure you have the right codes.

In an up-to-date list of information this year, are there any earth shattering changes? No, I would say not, because it doesn’t change codes that you’re already existing, that you’re doing. It’s adding some. So make sure, do I have the right and proper ones to identify what’s going on and what if they’re coming in from someone else and bringing that diagnosis.

I gotta make sure I have an accurate diagnosis and one that’s payable by example. Cigna has a different list in Aetna, which is different from United, which is different from progressive or other types. So keep in mind, know your coding, know where your payment’s coming from, the AC, the network. We’re always here to help you, but here’s one that’s interesting.

This one may not help you much, but this will be a fun one. At parties, there’s a diagnosis for everything. Do you know there’s a diagnosis for being a bad parent? The parent that’s hovers over the person too much that’s always there and always interferes in their life. That’s actually AZ 62.1. I.

A parent who is never there is AZ 62.0. So you can in a way give a person a really bad, or I won’t say a compliment, say something bad about them without them knowing it. But here’s an interesting, whenever you ever have a friend or family member that works in a hospital and they come home and can be like, oh my God, in the emergency room last night, this person came in, you’re not gonna believe what they put inside their body.

There are diagnosis codes for foreign bodies entering a natural orifice. These are all new ones. They’re in the W section. I want everyone to just give me a moment to think. We have a code that talks about you’re putting a battery or a button bat. So a decel or a button battery. A plastic object, A bead, a coin, a toy, jewelry.

And here’s what I find interesting. There’s bottles. But here’s the, I just find glass or sharp glass. And I guess there is a difference. There could be, nons, sharpp, glass. Here’s my point. Coding can be fun. You ever wanna say something bad about someone? There’s a way of coding it. What I’ll point out is there’s codes for everything.

So if you’re seeing something, trust me, there’s a way to code it. What I’m concerned about, is it something that is under acupuncture’s purview? Is it something we get paid for? And if it is, we wanna know it. The American Acupuncture Council, as I said, is your partner. The network is always here to help with that.

I hope to see you at a future seminar. Come January or at any time, become a member. Let me be part of your staff. Go out and do well. I’m wishing you the best. Code changes for this year. Don’t start in 2024. They started in October. Make sure you update your list, everyone. Until next time, take care.

Click here for the best Acupuncture Malpractice Insurance?

Get a Quick Quote and See What You Can Save

Most of you’re gonna hear something starting now because the Medicare enrollment period begins October 15th and goes all the way through, I believe, December 7th.

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.

Hey, greetings everyone. It’s Sam Collins, your coding and billing expert for acupuncture, the American Acupuncture Council, and really to make sure you’re getting paid. What I wanna go over now is Medicare. There is still so much confusion. I do seminars. I travel the world for on behalf of acupuncture. I deal with so many different groups throughout the United States, and I get so many calls from network members that are asking.

Sam, my patient called me and says they have direct Medicare or what’s going on, what’s changed? And what I wanna do is hopefully clear up a lot of the confusion ’cause in fact, Most of you’re gonna hear something starting now because the Medicare enrollment period begins October 15th and goes all the way through, I believe, December 7th.

So you’re gonna see probably a lot of television ads and other things talking about acupuncture and Medicare Part C plans where I find they’re actually using the profession to help promote their own insurance. But then what is the difference of these? What is Medicare? How does it cover acupuncture? Is it different from when it started in 2020?

So let’s get into that. Let’s go to the slides, everyone. You’ll see here. I wanna talk about Medicare and acupuncture update Medicare, part B and C. Do not be confused. A lot of people hear the term Medicare and it realize it encompasses a lot of things. The two areas that focus for acupuncture though are part B and C.

Part A is for hospitals, nothing to do with us. Part D is for drugs. And then supplement policies don’t affect US either, so it’s part B and C, and most commonly people get part B automatically. When you turn Medicare age, but many people now are trading for these part C policy. So I wanna make sure we understand the differences.

’cause part B has not changed when it comes to what type of acupuncture coverage there is. Part B coverage is still limited to chronic low back pain and so forth. So the problem is though, this is the type of thing are your patients are seeing the public, they’re seeing ads like this that says Medicare now will cover acupuncture for chronic low back pain.

They call Medicare and they say, oh yes, you can get acupuncture. Not understanding the differences with regular Medicare Part B. Yes, there’s coverage, but there’s some obstacles or some hurdles to cover to make sure it’s covered. The one that’s a little bit simpler, of course, are the Medicare Advantage plans.

These are the Part C. In fact, I like to use this one ’cause this is taken off of an ad from television for a Medicare advantage plan for UnitedHealthcare. In this particular plan I look at this and I thought, wow, this insurance company is using acupuncture to promote the sell of their service.

They’re letting people know, Hey, come and join us. Don’t have regular Medicare and you can get acupuncture for a zero copay. Is that gonna be attractive to some people? I think so. So certainly wanna look at that. And just to keep in mind, part B is what people automatically get. But many people are trading for the Part C policies.

In fact, you can tell that because look it, there’s ads all over the tv. Here’s one for Clever Care, Medicare Advantage. It doesn’t even talk about acupuncture in this part of it, but it’s showing someone talking about dentists and see your doctor, but showing someone getting needle. And obviously there’s a big push.

A lot of people are recognizing, Hey, acupuncture can be helpful for me. Where do I go? How can I go and does my insurance pay for it? ’cause particularly a Medicare patient, generally gonna be on a fixed income though, could, some can be wealthy, they’re still fixed. They’re joining, they’re, they’ve got pensions, they’ve got retirement plans, they have social security.

So they’re certainly gonna pay with their pocketbook, meaning they’re gonna look to see if they have any coverage. So the confusion comes in when someone comes in. How do we identify them as a Medicare patient? I’ll make a real simple statement. You’ll know they’re a Medicare patient. If we’re over 65, everyone in the United States that is over 65 gets Medicare.

Whether you want it or not, you get it. Now, the part A is the automatic, the Part B you pay a little bit for, but everyone does it. And that’s the card on the left. This one here, you’ll see that’s regular standard Medicare Part B. Notice it’s A and B. The one on the right, this is an actual card from someone that is a Medicare Advantage plan, and you’ll know it as such because you’ll notice right on the card it indicates.

United Medicare, silver. There’s golds and so forth, but you’ll see that, but this one takes over. Don’t be confused when a person trades their policy for a Medicare advantage plan. They’re not gonna make them give back their regular Medicare card. So when someone comes in, always ask them If using, let me see all of your cards.

Because if they have one of these advantage cards, this regular Medicare is gone. They’ve traded for this, and I believe this year is gonna be the first year. Last year, about 48% of people I. Change to a Medicare advantage, Part C, whereas 52% were regular. I think this year is gonna be the tipping point.

’cause these plans just offer generally a little bit more generous benefit and frankly better for us. So let’s talk about regular original Medicare part B, regular Medicare Part B. As far as acupuncture coverage covers only chronic low back pain, which is defined as. Back pain over 90 days. That’s not too hard with an older person, certainly, but still something we have to have.

The bigger issue though, is this. The chronic low back pain can be treated by an acupuncturist, but it must be what they’ll say is under the adequate supervision of a medical provider. Now, I want to take back here, you’ll hear some people say direct supervision, and in many instances it will be direct, meaning you have to be in the same office.

However, adequate could mean . If the medical provider feels comfortable enough working with you, they may not be in the office at the time you’re delivering the acupuncture. The problem’s gonna be, it’s not a simple referral. They can’t just refer to you at another office. You have to be working in the same facility, whether they work in your office and make your office part of theirs, or you go to their office.

So this one makes it a little bit more complicated. It’s probably a little bit easier in this way because it can also be a nurse practitioner. Or a physician assistant who are a little bit more traveling, but you have to be working with them because they’re who are billing it. You’re not billing directly.

You’re gonna be working for them, whether as an employee or an independent contractor. Now, the good news is adequate supervision means you might be able to have an arrangement where maybe they’re in the office two days a week. And on days they’re not there with the prescription, you’re doing the acupuncture and they’re supervising remotely, if you will.

That can be allowed. So keep that in mind. But it is not a simple referral, so don’t get confused. The other thing is they require very specific diagnosis, and I apologize for the typo here. I did redo this short just a moment ago, but the diagnosis codes you’re required to have are M 54 51. Which is vertebral genetic back pain or M 54 59, which is other specified meaning specifying is chronic.

If you use M 54 50, it’s gonna be denied. So I have a lot of people going wait a minute. My claim was denied. The simple reason didn’t have the right code. They do not accept M 54 50. But again, that part B one’s a little more complicated. I do have several offices doing it now that have done quite well.

But you really have to get someone that’s a medical person that you can work with. Remember, it must be medical doctor. Physician assistant nurse practitioner. It can also be a certified nurse specialist. Those three, it cannot be a chiropractor or physical therapist. Now Medicare Advantage Plans. Part C plans are ones that people trade for and frankly, this is the one you can bill directly.

So don’t be confused. Part B, no direct billing by an acupuncturist. Part C. Plans advantage plans will allow you, in most instances that you can, they do have the same parameters of coverage. They cover for chronic low back pain, but many of them offer what we call routine acupuncture, which means they pay for pain management, and these you can directly bill.

In fact, in many instances, you don’t have to be in network. But just willing to provide the service. The one thing to keep in mind though, you will be subject to their fee schedule. If you choose to bill a Medicare advantage, you cannot balance bill your full fee, but the amount they allow, frankly, it’s gonna be a little bit more than Medicare, however, so that part I will say is good.

Now remember, not all Part C policies necessarily will have the additional routine acupuncture, which means direct billing. Most will, but always verify. What I can guarantee is they will all have the chronic low back pain supervised, but you’ll see that coming up. When I show you a little more direct policy.

Now what does Medicare actually pay? And I think this is where a lot of confusion Medicare will pay for three sets of acupuncture. I. The initial set, and this is gonna vary, this is why I have the variation in fees. This is gonna vary depending on where you’re located. Different states, different counties all have different fees, kinda like house prices.

But you can say on average the first set’s probably gonna be 40, though I’m putting 40 to 55 ’cause some states are higher, depending if it’s elector, acupuncture as well. And then the additional set is 30, but it can be as much as 40, again, depending on the area. So I’m gonna highlight that for three sets.

It’s roughly a hundred dollars a visit. Now that does indicate about a 40 minute visit, of course, but nonetheless, a hundred dollars. I think for a hundred dollars visit. I can make that work. It is not great. I’m not saying you’re getting paid thousands, but that’s not bad. Assuming 20 visits, that’s $2,000 per Medicare patient of reimbursement.

Not to mention the medical provider gets to bill for an exam or other services they may do for that patient, but your services would be paid at about a hundred per visit. Now, Medicare part C policy, and I apologize, this is a little bit small. This is UnitedHealthcare one and up here talking about what is covered.

They’re letting you know the same as Medicare. What’s the same 12 visits to start? Eight visits if it’s showing improvement for up to 20 for chronic low back pain. However, many of these plans don’t require and or direct referral because they’ll have, as you’ll see here, acupuncture, Medicare covered, and then they’ll talk about routine acupuncture, which means.

They cover for pain management, and I’m gonna say to you, the majority of these Medicare Advantage plans usually have that benefit. So you’re not gonna be limited to just low back pain only, but just about any condition so long as it’s painful. Keep in mind, however, for back pain though, they too will still require M 54 51.

M 54 59 to give you a good feel for it. Take a look here. It talks about acupuncture C P T codes that it covers, and you’ll see here, even dry needling, if you felt so inclined to do it, I wouldn’t. Dry needling doesn’t pay very well and I don’t think you’re doing that. You do an acupuncture, but the four acupuncture codes, and then it says here, common routine acupuncture codes, not a complete list.

So what I wanna highlight, this plan is noting that they’re not just gonna pay for the acupuncture, but they’re gonna pay for exams. The acupuncture codes. But then notice they’re listing several therapy codes. In other words, they’re gonna pay you within the scope of practice for common services that are payable under the plan.

On these plans, you can see sometimes some pretty generous reimbursements. I’m not gonna bring some of those up because it’s way beyond what you may are be billing, and I don’t want to entice that. But I’d say on average some pretty good pay. So take a look here for an Aetna patient, this is for three visits.

Three visits with two sets. They’re getting paid $234. It’s not bad. I would take that and the patient only has a $9 copay. Would you think a patient might be interested in that? I would. I think a patient would certainly be interested in coming in if they only to pay a $9 copay for three visits. In other words, three bucks a visit.

Here’s another one for Humana for a single visit, you’ll notice about 67, again, two sets, if there were a third set, probably would be a little bit higher. So would I say these are ones that are viable to you and ones you can directly build? Absolutely. But just be careful. Regular Medicare Part B has not changed.

We’re working on it. When I say we, we as a profession are working on getting acupuncturists fully into the Medicare system that you can register. Then once we can do that, we’ll have direct billing that’s gonna happen that just don’t know how soon, I’ve, I could say two years, five years. I really have no idea.

We have to see if we can get Congress to get together. Vote for a speaker, , and then we can start voting on some real bills. But nonetheless, I think this is a real positive. Think of the number of people who have Medicare now realize 10,000 people per day become Medicare eligible. I would certainly wanna let people know I’m out here.

’cause when you are looking at this type of plan that’s paying you at least a hundred, maybe even as much as 200, would that be something that could boost your office? What if you got five of these per month? And keep in mind with these, you do have to bill insurance. Is that a big deal though? In my opinion, no.

If I have an insurance that I know is gonna pay me, I can figure out how to bill. That’s not that hard. But I’m not gonna accept everything, so I want people that are doing cash. Don’t be beholden thinking because you take one plan. Like for instance, what if you say, Hey Sam, I’ll accept Humana and United, but I don’t take Blue Cross Medicare Advantage.

That’s your choice. Remember your choice to what you wanna bill is there, but keep in mind, it’s your choice. If the patients come in, they probably can have zero or very little copay on these cases, and again, can pay pretty decently. I would say look at what your cash price is. Anything that gets me up equivalent to that, that billing is simple and easy.

I’m all in. ’cause realize all of these plans will have portals where you’ll be able to bill electronically and so long as you do it through their company, it is going to be free. So I say, why not? So be aware. You’re gonna see a lot of this coming up because we’re in the enrollment period. Take a look at the commercials coming up.

They’re promoting your business. Let’s make sure we’re saying, Hey, you know what, we’re here and available here would be the thing though. How does someone know they even have benefits? Have you ever put anything out in your office that says, we accept Medicare or Medicare Advantage? Because otherwise they’re not gonna know.

I still think a lot of people don’t understand there’s even the benefit, so we wanted to start to do things to promotes that people know there’s access, and particularly for the plans, we know that are the good plans. As always, I’m here to help. We do seminars. By the way, what year is it right now?

It’s 2023 Sam, but what updated this month? Diagnosis codes. If you’ve not been to a seminar with me, you have a few coming up. You may want to get there to understand there’s been some coding changes, particularly for migraine headaches. Where will you know how, what fees to charge, the Medicare rates? All of that stuff is something we cover.

We do our network services. Just go over our website. We’re always there to help and I’ll bid you a due. Until next time, everyone, thanks so much. This is Sam Collins and I’m out. . .

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. Welcome back in. Thank you, American Acupuncture Council. Let’s make sure the profession continues to understand its growth and its potential. One of the issues I deal with a lot is documentation and coming from being the acupuncture coding and billing expert, I get this lots of times.

I recently had a call from a special investigator. From the Department of Banking and Insurance in New Jersey, I’ve dealt with this in Florida, California, and frankly all over to some extent, and it’s about documentation of acupuncture. Now, frankly, I don’t care whether you’re billing insurance, you’re doing cash, doing a combination, you still have to have your information documented.

It’s not very hard, but what you may have learned has been updated. And one thing to keep in mind, acupuncture is a profession. It’s not a perfect meaning, it’s a practice. You’re always learning and updating and one of the things you have to keep in mind is things have updated and I think there’s a lot of misinformation when it comes to acupuncture documentation, which I will go back and say, not very hard, it’s what you do, but have you ever really thought about what does it require that I have to have down?

Whether you agree or disagree with some of the aspects, frankly doesn’t matter. ’cause we have to go back with what is the standards set aside by law. And of course the profession itself. So let’s go to the slides. Let’s talk about Accu Acupuncture documentation, and let’s talk from it this way. We want to assure your documentation simply matches the services performed.

What if a patient makes a complaint that you didn’t, you charged them too much for the services they did. This is cash, and your notes have to back up what you’ve done, or it’s an insurance or any aspect in that way. So don’t be cavalier thinking that, oh, I don’t take insurance. I don’t have to document.

Not at all. I. Your liability is such that if you didn’t document what you have performed on that patient, it didn’t happen. So let’s assure documentation matches the services performed. Here’s one of these insurance claims that I get. A lot of these, because obviously people are billing insurance. It pays well in a lot of aspects, but you get back saying, we’ve looked at your notes and they weren’t well done.

Now, some of you may know I’m actually on the board. Or what’s called the Coding and Reimbursement Committee for Optum Health in United Healthcare. That doesn’t mean I work for them, by the way. It just means I’m an appointed member that oversees things. And one of the things we commonly run into that are problem for acupuncturists is just improper documentation.

In fact, in many ways, acupuncturists for documentation are low hanging fruit because often it’s never been learned or taught. How to properly document. So take a look here. What does it say? This office is billed out an initial set of acupuncture and it says the information submitted. This means your chart notes is, does not contain sufficient detail.

The submitted records don’t support. 9 7 8 1 0 was performed. It goes on to say it for the second set. Claim cannot be processed as billed. The code requires a proceeding procedure code, which means this one, and it’s not supported. We see this time and time again, not just with acupuncture. Here’s some more of that.

The documentation does not support the services billed. In other words, if you’ve collected money for something, you have to make sure you’ve shown you’ve done it in a way. This is a receipt, if you think of it, your documentation is a story, but a receipt or indication of what was done on the visit and the results of it.

So over and over we see this. Investigational services, but notice here, services not rendered as billed. Just simply documentation. Take a look here for 9 7 8 1 1. What it says is the each additional 15 minutes of one-on-one service, there are multiple examples where there’s conflicting information with respect to the time spent with the patient, and in fact, notice this one, 42% of the claim lines had no supporting documentation.

Just writing a date and saying they had acupuncture is not sufficient. Again, I want to emphasize, This is not about insurance, it’s about what’s documented about your patient, what was provided. So let’s take a look. What does it say in C P T? What do we have? Now? Keep in mind these codes have been in place for 20, or excuse me, 18 years, ’cause it’s 2023 and they’ve been in place for 18 years.

When I see people not understanding this, it frustrates me. ’cause I’m thinking when did you graduate in the seventies? So take a look. It says acupuncture, one or more needles. So what does acupuncture require? You insert needles if you don’t put needles in. It’s not acupuncture in the sense of a billing code or a service, so you have to put needles in, and then it says, With one-on-one time.

In order to put the needles in, you have to spend time with the patient. And acupuncture codes, as I’m sure you’re well aware, indicate 15 minutes and you’ll see this time and time again. The initial set needles in 15 minutes, the additional set needles in 15 minutes. So this is not unique, it is not new, but it’s something we have to make sure that we have.

So again, taking a look, needles time and needles. Now I think we’re often, we get confused is do I actually have to write the time down? Yes. If you are doing a service that is time dependent, there has to be time somewhere. Now, here’s the good news for the profession. Acupuncturists, I would say in my experience, and I’ve been around this 25 plus years, probably spend more time with their patients.

I. Most other providers, partly because the service you provide is very specific for time and things you’re doing, but also because of the things you have to evaluate, realize all of that is included. So what I want you to think of is what time am I documenting? Literally, if you’re doing acupuncture that day, the time starts as soon as you walk in the room and say, hi, Mrs.

Jones, how are you? It starts. So you’ll see here it says, how is the 15 minutes of time defined? Let’s make that larger so it’s easy to see. The 15 minutes of time for acupuncture includes lots of things. Basically everything you do when you contact the patient soon as you walk in. This would include a review of the history, so you know when you walk with room and say, Hey, how are you feeling?

Is it better today or worse? What’s happened over the last few days? That time counts towards acupuncture. It includes your day-to-day evaluation. Some of you may do tongue and pulse. Some might do range of motion. You might do some other testing. That’s all fine. It’s included your day-to-day. How is it feeling?

How is it better or worse? Notice, hand washing, sanitizing your hands, choosing and cleaning the points, quite frankly. Opening the needles, getting them ready to be put in the patient. All of that counts as well as the time it takes to insert the needles, making sure they have good grasp. You’re in the right point, making sure it’s all good.

Actually asking the patient how that feels would include. So that includes inserting, manipulating. Now, what doesn’t count is once you’ve put the needles in and the patient’s just laying there to rest without any interaction, that would not be considered part of it. But let’s say the patient is on the needles, but while they’re on the needles, you’re manipulating them.

That would count, but what also counts is the time that you’re in the room, again, removing the needles. Including notice here, completion of chart notes. So removing disposal. So I want to keep in mind time, just tell me when you’re in the room with a patient doing anything that’s part of acupuncture.

Now an exam is separate or if you’re doing another therapy, but the majority of what an acupuncturist is providing a course is acupuncture. Tell me the time. The only thing that really doesn’t count outside of the exams and therapies is the time the needle are retained. Isn’t included because that’s not something you’re time dependent by example.

Not unusual. I know the acupuncturist I’ve been to often I’ll have neuros needles inserted and I’ll lay there 10 or 15 minutes relaxing, maybe listen to some soft music or something of that nature. Nonetheless, that time doesn’t count. So here’s what we have to document. Don’t make this hard document the time and the needle.

So here’s two examples to, and I’m gonna give you a couple of examples to try to give you a feel for what you want. Now realize . There’s gonna be many ways you might do this, but it’s gonna fall somewhere in this range. Notice here it says clearly treatment or needle set one. I would prefer that you indicate which one is set, one or two.

If you’re doing multiple sets, say it. Say this is set one notice here. It’s indicates face-to-face time. So here it says 20 minutes and it says what needles or what points were needled. It lists all of them. And notice it actually indicates there was estim added to these two points, U B 62 and G B 34.

So that means that this set, because there’s electricity at it, becomes an electrical set. Nothing more complicated. It doesn’t have to be every needle, just even two. So notice what it does time. Points. Notice, it does indicate, Hey, the patient was rested on needles for 12 minutes. That’s fine. Now what if you just stay in the room with the patient and you’re continuously needling?

That’s all face-to-face. We just have to decide what’s points were in the first 15 and second 15, but nonetheless, showing here time and needles. Not complicated. Get in that habit. Notice it says here, after the patient rested with needles, they were withdrew and repositioned. Now let’s keep in mind, do you actually have to withdraw the needles?

I. To insert a second set. No. You may or may not. I’m not gonna say one way is better or otherwise. Obviously, I guess if one is a front side set and one’s a backside and they’re laying face down, face up, probably, but outside of that, no. They don’t necessarily have to be removed. In fact, commonly when I’ve been in, and I can again leave my own experience, I’ve had needles inserted and then just additional ones were put in, that would be a second set as well.

But notice how it’s documented. Treatment set two. Face-to-face. Time on this one is 18 minutes. What points did we needle notice? They added some ones with electricity. So clearly. Was there enough time for set one and set two with the points documented? Absolutely. So start thinking of how am I gonna do this?

Whether you’re doing paper notes, electronic notes, simply tell me your time in the room, face-to-face with a patient doing something that’s part of your acupuncture, along with the points you’ve inserted. Not very hard. Now you may question what about time? I did a program on that. If you’re not familiar with the 15 minute and the eight minute rule, go back in the R archive.

We have that listed there. But here I just wanted to make sure. Notice how simple that is. Don’t overcomplicate that. What you don’t wanna do is say I needle the following points and say I spent 30 minutes. Because if I do that, am I dividing into two sets? Make sure that it’s clear that what needles were in setted for set one or set two, or during that period of time.

Here’s another example. Now this is a full chart note. You take a look at that, but I wanna focus on just the documentation of the acupuncture. Notice what this one does. Pretty much the same thing, but just done slightly different. Notice it says each set of acupuncture is set one, two, and three.

It says the points that were inserted or reinserted. So it’s real clear that there were needles inserted. It tells you the face-to-face time, and if there’s separate retention, it does it. So notice this one. It names three points, the time spent. Now you might think we’ll see ’em. Come on. It wouldn’t take me 25 minutes to insert three needles.

You may think so, but realize the insertion of needles is not just the physical time of inserting the needles. All the things that you do with the patient to determine where you’re gonna put those points. The time to clean your hands, put the needles in, make sure there’s good grasp, realize all of that counts, including, let’s say, when you come back in the room, I.

To remove them. So notice each set clearly set aside for each one and time. Now, notice the other one said it spent 18 minutes or 20 minutes. Notice this one says, from, and two, frankly, it doesn’t matter according to C P T and the standards. So long as you indicate whether it’s minutes or from, and two time, it’s acceptable.

Just make sure it matches what was billed. So I’ll say to you, don’t overcomplicate this. Don’t be confused because well, in school I was told this or that. Again, sometimes what you were taught in school may have been old information. Or let’s face it, we all have biases. So what if you had an instruction that goes I disagree with it.

I will tell you, I don’t necessarily have an issue with someone agreeing or disagreeing, but I do have to go by what does the law and the rule state. So long as you’re within that. This is not hard. In fact, I would say to most acupuncturists, the one thing that I think most acupuncturists take pride in is the amount of time you spend with your patients.

Document it. It has value. You’re inserting needles. It all counts. We’re here to help realize, this is what I do on a day-to-day basis, is helping offices deal with problems to say, let’s take a look at your notes. Let’s make sure they’re okay. That’s what we do with our network members. If you’ve not been familiar with it, take a look.

Also note, we have seminars upcoming coming soon, because remember, October 1st, I C D 10 does update. There’s gonna be some new codes out there that are specific to acupuncture providers, so always know that we’re gonna be your resource. The American Acupuncture Council Network is your place for seminars and for day-to-day help.

Take care everyone. . .