Tag Archives: Sam Collins

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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.

 

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Are Vaccines Mandatory for Acupuncturists?

 

 

What’s happening, what’s mandatory, what’s mandatory. What’s not mandatory. What can I do? What do I have to do? And who can tell me to do it? So let’s go to the slides and let’s talk about what is mandatory and requirements for an acupuncture provider.

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 and information network, as well as the insurance company, of course, and welcome to another edition of, to the point and how to make sure your practice is doing well. This time, the topic is not going to be on coding and billing, not this week because obviously with a lot that’s going on very timely because we’re now getting close to October is what’s going to go on with vaccines. What’s happening, what’s mandatory, what’s mandatory. What’s not mandatory. What can I do? What do I have to do? And who can tell me to do it? So let’s go to the slides and let’s talk about what is mandatory and requirements for an acupuncture provider. As far as vaccines are concerned, do I have to get one and who can tell me to get one?

So you want to think about who can mandate, well, several things. There can be a mandate by the government, whether it be the federal, it could be the state, even local. You might have a city or a county. And then of course also private businesses may do so as well. So we have to remember, let’s look at, to see who is doing it, what they’re saying we have to do, and whether or not there’s going to be compliance for it. Because one of the things that’s occurring is a lot of people have gotten misinformation about who’s doing, or when they’re saying it, who they actually are including. So let’s start work first with this misinformation and misinterpretation. So you’ll see here in July 6th, the office of the alphas of legal council mandated that they said, no, we can do vaccine mandate. So there’s nothing constitutional.

We can say, oh, well I have a private citizen, right? And so forth. Well, we have a lot of rights, but do you have to wear a seatbelt? You know, do you have to wear a motorcycle helmet in some areas? So it’s that type of thing. So be careful if someone’s saying they can’t do it, they can, we have to look at, are they mandating it for us to do it? So let’s go here and let’s talk about federally, what’s happening for Medicare. So you’re going to see here at president Biden, you know, back a few weeks ago, made this big statement about Medicare, that Medicare is mandating it and they have to in federal and everyone was up in arms like, oh my God, is it going to have to be something we have to do? Well, they made a mandate that it said, yes, the key is, does that include acupuncturist?

Who does it include? And it’s often says facilities and people wonder what’s a facility. Well, facility generally is going to be a facility that provides services within it, such as a hospital, skilled nursing, that type, not generally individual provider offices. So with that said, what about the Medicare part under the federal? Does that apply well currently, of course. And I’m sure you’re well aware. Can an acupuncturist join Medicare? No. So that means absolutely not. Now a quick note, is there a bill right now to get acupuncture, to be part of Medicare? Yes. So make sure you’re supporting it. But as of now, there is no mandate for acupuncturists to even be in Medicare. So we want to be careful. That’s not part of it. There is a mandate that for Medicare facilities and providers, hospitals, that doesn’t include individual providers fee for service providers. So let’s just say you are working in a Medicare facility like within a hospital or a big clinic there you might be.

But for most of us, we’re working in private offices. So even if we were in Medicare, we wouldn’t have to, in fact, look here, it says a spokesperson directly. And this was just a week ago. This regulation does not directly apply to physician’s offices. If these are considered regulated under the provider specific Medicare health and safety regulatory provision, generally referred to as a condition of participation. In other words, in simplest terms as an individual provider, even if you were treating Medicare patients in a private office, you do not have to have a vaccination. So the federal rule actually does not apply to everyone. Now, if you are a medical doctor working in a hospital, yes. If you’re a nurse working in a hospital, if you’re an acupuncturist working in a hospital and there’s a few of you, that could be, but so long as you’re working in a private office, absolutely not.

So that being said, let’s talk about the conclusion of this and really what it means. Acupuncture providers can’t even join Medicare. So the, the mandate really doesn’t match. The only way it would, as I mentioned, would be if you were working inside one of those facilities. So again, from the federal level, nothing to worry about as far as a federal mandate for an acupuncture provider to do a vaccination or have a vaccination. And remember when they’re saying vaccinations, they’re also referring to also staff. So let’s talk about another federal plan. I’m sure many of you have heard or seen the VA made an announcement that they’re going to require vaccinations. And so here is on July 26th, they said the department of veterans affairs, making vaccines mandatory to all VA health personnel, including physicians, dentists, podiatrists, optometrists, and even went so far as to say anyone doing veteran administration through the VA choice program.

And so of course, everyone’s like, oh, what does this mean? Is this something that it’s going to be mandatory for me? And of course they had to make a clarification because everyone were all upset. Like, no, and you’ll see here. It says, and this is something the VA has posted. They are not requiring community providers, which is where acupuncturists fit. If you are working in your office as a community provider on a standard episode of care, where they refer a patient, there is no requirement for you, whether you belong to the Optum on the east coast or try west on the west coast. Now they do say they strongly recommend that you should have the vaccine, but there is no mandatory requirements. So both on the federal level of Medicare, the federal level of the VA, there is no requirement for vaccinations unless you’re working within a facility doing those services.

So by example, there are acupuncturist who work in the VA hospitals, or work in the big VA centers for those acupuncturist. If you work there, you will be vaccinated as every provider within that. Heck if you’re a janitor in those types of facilities, you are going to have to do, um, a vaccination. Well, let’s move the next step. What about state rules can states make that happen? So the first one I’ll point out here is for California. Now this is just an example of one for California. The department of health first came out and said they issued a mandatory vaccine for offices. And of course, everyone was like, what lost their mind going crazy? And I always will say, make sure that you understand the full rule read in detail. You’ll notice here. They made it mandatory. But however it says, we have exemptions which include acupuncture offices.

And in fact, this includes all types of facilities that are not covered under this order. So this means acupuncture offices. And of course all the rest of these meaning chiropractic as well as natural paths and almost every individual office occupational therapy, okay. Optometry offices, podiatry offices, physical therapy places. So in other words, it’s really, again, kind of going back to the facility areas, not the individual providers, again, facilities. So California does not have a mandatory facility for you even first days. If you work at a theme park, some people that if I’m a theme park nurse, I have to do it. So pretty much exempt except facility. So I will go back to kind of California followed the mandate of the federal government, which said facilities. However, we have to be careful. Some states are pushing it. So by example here, what about the state of New York?

Well, New York has made a mandate that says as of August 25th, their regulations include a broad vaccine mandate for New York health care facilities. So again, I want to use this term broadly and say facilities. And so here are the emergency regulations apply to each of the following types of categories in the state of New York, which is going to be general hospitals, nursing homes, okay. Diagnostic and treatment centers, including without limitation, community providers and birthing centers, again, big places. And then along with that certified home agencies and so forth, but I will highlight again, home health in person hospices, but this does not include acupuncture, adult care. So notice again, kind of the facilities area of this. That is where it applies. But while California New York don’t what about the state of Washington? Now, Washington is a bit different now you’re thinking, well, Sam, I’m not in one of those states.

What I’m going to implore you to do is make sure to check your state. There’s only a few that are, but definitely Washington is making an issue Washington as had a proclamation by the governor that on August that they’re requiring it. And within this, this means that you are mandatorily required to have vaccinations. And it has to be by October 18th. So this status includes again, acupuncture offices. It includes every employee providing healthcare. So it means everyone in your office, which means this is going to be difficult. Every one of us has to be within this. And it does mean acupuncture providers are included. So Washington’s going to be a bit tough. Now, are there exemptions you might be able to have absolutely. There can be exemptions, but it’s mostly religious exemption. So I would be careful, I would say, make sure, make sure that you verify within your state.

Cause I’m going to tell you for Washington right now, they’re pushing the issue. Now what’s going to be interesting is how are they going to enforce it? Are they going to require each licensee to send information? And they may, well, what if you don’t send it, could they suspend your license for a while? Possibly. So something I would look at well beyond the state of Washington there, again, as I mentioned, there’s exemptions, but I want to highlight Oregon is doing the same thing. Oregon is requiring it by October 18th, as well with no exemptions other than religious. So again, know your state. So if we go down just the west coast, Washington, Oregon, yes, California, no New York says no, at least for us, but you’ve got to be careful. So again, on a state level, if your state is enforcing it, please look at your licensing board, make sure, check with legal counsel to make sure am I in a position where I’m willing to fight back on this or do I just have to get the vaccination?

That’s gonna be a tough choice for some obviously, well, let’s move on to the next thing here. If the healthcare provider works in a healthcare setting, they must register request accommodations for the operator, which means, again, be careful of these exemptions. If your staff says that they can’t be there certainly could be healthcare concerns that do it. If they have a healthcare issue that doesn’t allow them, but be very careful. Am I really doing things that are vaccinated? It says if an individual does not qualify for an accommodation, they must get vaccinated. And notice it says, testing, not allow. There are some states that will say, Hey, no vaccine, but get tested. California is doing that. But of course that means for us, it doesn’t matter. Cause it’s not a requirement. But if you’re working in a facility, they would require this testing. So others are pushing back.

Well, what’s the next place. Okay. So we went from state and I get I’m an employee to look at your own state. What about local employers? Can they do it? According to legal side, a private company is allowed to mandate vaccines. You know, kind of private company mandate a lot of things, dress code, and otherwise in the United States, you’ll see here in the second box, mostly our employers and employees are at will. And this employment means you can be dismissed for anything, which could be, Hey, you relate to times this week, but if you won’t get vaccinated, so it becomes one of those ones. If local is doing it, meaning an employer, they could enforce it. Now could you try to bring a lawsuit? I’m sure you could. But in the, between of the lawsuit, would they allow you to continue working? Probably not. So I want you to be very conscientious of knowing within the rules of what is having to be done.

I’m not finding for us, that’s going to apply as much because you’re the employer. But let’s say you’re employed by someone. What if you work in an office where you’re with an MD or a chiropractor or anyone else and they mandate, Hey, we want you to have that. Well, I’ll give you an example. Take a look at this. Does Disneyland. If you work for Disney, can you have facial hair? Do you know up into 2000 at Disneyland, you could not have even a mustache. Even though Walt had a mustache, Disneyland wanted to be clean cut and no one could have facial hair. So that meant if you wanted to grow a beard, you can, you’re just not working for Disney. And so Walt had one, but up into 2000, you could have a very small trimmed mustache. Now the rule is you can have facial hair, it’s allowed, but notice what they say.

Employees are allowed to have beards as long as they’re kept shortened and trim. So what I’m bringing this up for is that always understand who has the right to do it as an individual. Do you have a right to say, I don’t want to do something. Sure. But that could mean you don’t have a right to like come into the business. For instance, could you say, I don’t want to wear clothes and go into a store or I don’t want to wear a shirt. Let’s not even go that far to just say no clothes at all. And we all know that no shoes, no shirt, no service. So the same thing applies. What I want to make sure is I hope most of you were on board with this, but I will tell you many of you have not. And I’m going to ask you, where are you getting your information?

This is the webpage of the American acupuncture council network. And I want you to see, I put it in red here talking about federal vaccine mandates do not include acupuncture offices. We’ve put in three times this. So if you haven’t already go to the American acupuncture council network page, go to the new section and sign up for our newsletter. Cause we keep you constantly updated as to what’s going on. And I want to just as a little tease, do you see that one I highlighted in blue? It says ICD 10 updates happen. October 1st include new new codes for back pain. How many of you were aware of that? So a week from Friday new codes for back pain, are you on top of that? The American acupuncture council, we’re here to be your resource, the network, especially seminars, our network service. If you don’t have a place to get this information correctly, you’re going to be lost.

Remember the internet is not your friend when it comes to this information because there’s just as much bad information come to the trusted resource, go to our site. If nothing else, at least get into the new section. Because if you don’t, we’re going to have some problems. Please make sure you’re always set to understand what’s new, what’s changed. And we’re always that resource. So be careful. Do I have to get a vaccine on a federal level? No VA level, no. Some states, yes. I gave just a few examples. So make sure, and of course, if you work for someone, it could be from them. If you need to know more information about that, we are the place to go. So what I’m going to say to all of you is thank you very much. If you want the resource go to our website, it’s just simple AC info network. We’re going to help you. We do continue education and much more than that. And for next week next, our host will be Poney Chiang. Remember the American Acupuncture Council is always your resource. And if you don’t have the right information, you’re likely not getting paid. And of course we want you to get paid. See you next time, everyone. Thanks for being with me.

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What Modifiers Are Necessary On An Acupuncture Claim?

 

 

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

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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CIGNA ASH Update for Acupuncture Providers – Sam Collins

 

 

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

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

And we’re Live. All right,

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

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

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

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

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

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

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

More volume and will it make up

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Sam Collins for AAC02102021

Do Not Risk Loss of Payment! – AAC Infonetwork

 

 

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

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For neuromuscular education. It is, it is for

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

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

Acupuncture. And you’ll notice the map

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

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

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

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

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

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

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

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

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

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

Please subscribe to our YouTube Channel (http://www.youtube.com/c/Acupuncturecouncil ) Follow us on Instagram (https://www.instagram.com/acupuncturecouncil/), LinkedIn (https://www.linkedin.com/company/american-acupuncture-council-information-network/) Periscope (https://www.pscp.tv/TopAcupuncture). Twitter (https://twitter.com/TopAcupuncture) If you have any questions about today’s show or want to know why the American Acupuncture Council is your best choice for malpractice insurance, call us at (800) 838-0383. or find out just how much you can save with AAC by visiting: https://acupuncturecouncil.com/acupuncture-malpractice-quick-quote/.

 

E & M Code Evaluation 2021

2021 Evaluation and Management Coding Update


“So I want to give a little bit of an introduction today as to what’s occurring to at least give you a feeling for it. Certainly this is not going to be what I can fully give you at a full seminar and a, through a consultation, but at least to give you some updates enough to be able to get in, to handle what has changed. So E&M codes, evaluation, and management, or if you will, exam codes are being updated for 2021. So I’m sure you’re all familiar with what a hat we have had of course, in the past, which of course were the standard E&M codes.”

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hey, welcome everyone. Happy new year.

Glad to have you with me. Thank you to the American Acupuncture Council for giving an opportunity for us to share with you information, putting in billing and really making your practice for the new year. So happy new year to everyone. And of course, year of the ox. And I also will tell you, it’s going to be the year of time. I’m Sam Collins, the coding and billing expert for acupuncture. In fact, you probably see multiple articles from you and acupuncture today and other publications, as well as I’m on the United healthcare committee for coding and reimbursement sitting for acupuncture’s behalf, as well as who for ICD 11. So I have a very vested interest, of course, in your practice, in the thriving of what you do. Well, of course, this year, like all years, there’s always something new and updating, and I’m sure some of you have already noticed there’s been some changes that have happened with E&M (evaluation and management) codes.

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So I want to give a little bit of an introduction today as to what’s occurring to at least give you a feeling for it. Certainly this is not going to be what I can fully give you at a full seminar and a, through a consultation, but at least to give you some updates enough to be able to get in, to handle what has changed. So E&M (evaluation and management) codes, evaluation, and management, or if you will, exam codes are being updated for 2021. So I’m sure you’re all familiar with what a hat we have had of course, in the past, which of course were the standard E&M (evaluation and management) codes. Now, when I say E&M (evaluation and management) always remember that means evaluation and management. So that means evaluation the exam management, the, you know, dealing with the patient, discussing with them. And I’m sure you’re all pretty familiar with these codes in the sense of we have new patient codes. And of course we have established patient codes. What, what these codes are, for course are simply for exams. These codes are no longer going to be there. At least described this way. What they’re doing is trying to make this a lot easier to deal with. So obviously you’ll see these codes. And I think the one thing we all picked up on that was always, there was things like this. You’ll notice here. It says physicians typically spend 10 minutes. Well,

I’m sure you’re all aware that never was the reason

For the code. It was not something based on what’s typical, but what was considered an average and more about what you did on the exam. Now, a quick note, what is not changing is the definition of a new patient or established patient. A new patient of course, is going to remain the same. That’s someone brand new or office or someone you’ve never seen before. Okay. Meaning I’ve never seen them, but it could also be a patient you haven’t seen for three years. So do recall the three year rule when it comes to a new patient, even if it’s a past patient, but they’ve not been to you within three years or more, you may build a new patient again. So that’s the new patient code that’s not changed and established patients not changing either. That’s any exam of a patient that’s existing. Existing means anyone you’ve seen within three years.

So it could even be a new injury, but it also obviously would be a re-exams. So what’s changing. So I kind of chose this Bob Dylan kind of theme times, they are a changing and this is really a dramatic shift and what’s changing. So the bottom line is the codes are changing, but I want everyone to be aware if you attended a seminar with us, the American acupuncture council that I’ve taught, I’ve actually been teaching these changes since 2019. So hope you have a little bit of information if you’ve been there, but let’s keep this in mind. I’m sure most of you are aware. The old way of coding was pretty complicated. There were a lot of guidelines that you can see here. The 1997 documentation guidelines was 50 pages long. And in this guideline, you’ll see all of these things where you had. If you see on the left side here, all these organ systems that you had to have, and then of course it was the number of bullets of what things did you do?

Did you do a range of motion? Did you do palpation? Did you do tongue? And these bullets added up, so you had to have kind of a scoring. So familiarly, if you were billing a nine, nine, two Oh three, you had to do at least two or more organ systems in 12 bullets, which for most people was like, I don’t understand what you’re talking about, or it becomes complicated on the way that acupuncture is, do it. And I’m sure if you’ve been to our seminars again, you’ve seen this guideline as well. That talks about for each code. So notice each code nine, nine two Oh one to two, one two says problem-focused expanded, but you’ll notice it talks about the number of bullets. This is what was complicated. And frankly, this is the reason they’re making a fairly big change with this. The reason why is finally CPT, I think did something to less complicate.

And I won’t say CPT is necessarily trying to complicate, but they’re trying to make it accurate. Well, what they realize they needed to do something with these codes because they really weren’t working for the way doctors examined patients and particularly acupuncturists. And the whole point of this change is to increase time with your patient. Not doing a lot of other works, like doing certain bullets, just to meet the guidelines. It should improve the payment accuracy as well, because it allows you to truly pill a code that’s accurate for what you do, because I’m sure some of you as an acupuncturist are pretty frustrated that often you might spend 30 to 45 minutes with the patient, but yet the exam based on the old guidelines, it might only come out to a two Oh two and you’re thinking, Oh my goodness, I spent 45 minutes. So this update is really reflecting that.

And so what’s happened is these new codes now indicate a focus on time. Oh, let me go back here. And so you’ll notice here. The first thing you’ll notice is nine, nine two Oh one has been eliminated. So you’re never going to use nine, nine two zero one. Again, what we have now for new patients is nine nine two zero two through nine nine two zero nine, excuse me, nine nine two one five. So two zero one has been eliminated. So some people are like, Oh, this is going to be a problem. So take a look here. You’ll notice. Now this code says it’s an office or other outpatient visits. So notice it doesn’t necessarily say exam though. That’s part of it. And it says for the evaluation and management of a new patient, which requires medically appropriate history and examination and a straightforward medical decision-making.

Now you may look at that go, well, what does straight mean? Well, it means it’s fairly minimal, but here’s the best part. Take a look at this. And this is really something excellent for acupuncturists. It says here, when using time for code selection, 15, 29 minutes of total time spent on the date of the encounter. So in other words, the big change for this year is time now becomes a focus that you can use should choose the appropriate code. So if you Ben 15 to 29 minutes, the code would be nine 92. Well, too, if you spend you’ll notice here 30 to 44 minutes, it will be a two Oh three. If you spend 45 to 59 minutes, a 200, and then if you’re going, obviously plus an hour to up to an hour and 14 minutes, it would be a two Oh five. So now what you can do as a provider, start to log the amount of time you’ve taken with the patient.

Cause understand that the time you spend with a patient, not always as doing exam things or palpation, right? If you will, but taking the history gathering. In fact, here’s the really cool part about this. Notice this statement here, it says of total time spent on the date of the encounter. So no longer is it just face to face time. It’s now going to be the entire time. So by example, I bet many of you have a patient fill out a relatively detailed history form. And of course, once they fill that out, you’re going to spend maybe five or 10 minutes reviewing it before you even go in the room with the patient, because you want to see what they said that week and ask more points, questions. Here’s the important part of that. You now you can take the time you did reviewing that before seeing the patient, this is before or after seeing the patient so long as it’s in the same day, it doesn’t have to be face-to-face.

So now I want you to start thinking not only is time important when you document acupuncture, as we’re all aware, but it now also becomes important when doing evaluation. So it’s going to be important if you will to think of it. This is the year of time. I know it’s the year of the ox, but it’s the year of time you’re going to time acupuncture. But now I want you to start to tell me how much time you spent doing any of the activities that are running [inaudible] to your acupuncture visit or exam it could be, or the patient or after if you’re having to review or, you know, probably, uh, consult with another doctor potentially. So you’ll notice all of them have a time value. Now that’s different. So this is a completely new description. That old description is now gone. Now, the other thing that did update a little bit, they did obviously indicate time.

But one thing to note nine, nine two, one, one you’ll notice here does not have a time value. And that’s because that’s considered a value for a non doctor seeing the patient like a staff person, which wouldn’t happen in a Kairos or excuse me, an Accu setting, but maybe in a medical setting, they might have a staff taken a blood pressure. So think of it this way. You’re going to code a nine nine two one one. You’re always going to code. According to time, notice on a re exam of a patient 10 to 19 minutes. Now as a two, one to 20 to 29 minutes is a two, one three. So where I think things are going to be a lot easier for acupuncture. Now, just going to document the time now I will say, let’s be a little careful. If you tell me you spend an hour with every patient, no matter what they have, that’s going to be problematic because now it’s not an issue of what you’re seeing.

It’s a style, but assuming you do more or less, depending on severity, this all makes a lot of sense. And so now you’re simply going to pick the code that’s appropriate. I do believe you’re going to see a lot more potentially two Oh threes and twos, zero fours, based on that timing of that first visit. However, I do think on the re-exams we might be more in the 200 threes and two, one twos, not the two, one fours. It goes on re-exams will you spend more than 30 minutes on the re-exams? I won’t say that is this typical, but not saying not here’s the important part document the time. So here’s, what’s changed the old really based everything on the complexity. And you had to have history of physical exam, medical decision making, and it had to all fit within these guidelines. Well, the new one no longer requires a specific history or exam.

Now that doesn’t mean there isn’t an importance to a history and exam. It just means that’s not going to be the absolute basis for the codes. They’re going to allow you to use the time that you spend with the patient. If you will counseling them to an extent, in addition, they will still allow medical decision making. That’s what MDM stands for here, medical decision-making. So this is where I’m sure some of you have seen this. You can go to a medical doctor and maybe you’re with him or her all of 10 minutes, but they Ville bill a very high value code and you think, Oh my God, how could they build such a code for 10 minutes? Because the medical decision-making being life or death or something that with a great risk of morbidity, mortality may be higher. So there’s still going to be a component of that.

But I think this really helps complementary providers like acupuncturist, better code according to the amount of time and things you need to do with the patient. So to kind of give a synopsis, you’ll notice nine, nine, two Oh two to two Oh five. You’ll notice the total minutes here, but then notice it says medically appropriate. So do keep in mind. If someone comes in with a simple shoulder pain, I doubt that’s ever going to reach a high level, even if you spent an hour. Cause what about that would be high in the sense of risk of morbidity mortality, but what if they have multiple areas? What if there’s low back pain and it’s rated into the stomach? Those all certainly could make a difference. In addition, notice now on the right side as well, it says medically appropriate for the established patients. But notice again, just the time and what it says a straight forward, think of straightforward is something you can almost see it without really even evaluating just based on the patient telling you, but the more complex, the more things we have to do deal with.

So I do want to make an emphasis here. History for an exam is no longer the reason for the code. It could be medical decision-making or time you should do an appropriate history and exam for the patient’s condition. Obviously, would you want to do a full history of a patient with a simple shoulder problem? Probably not. I mean, we don’t need as many of those factors as we did in the past just to qualify, but it would be appropriate necessarily based on the history of the patient. Tell you, so it says here healthcare providers should not interpret this change to mean that the documentation efficient exam is not necessary. A complete medical record of services is rent. Rendered is important for many reasons, such as providing information for quality initiatives, but also making sure that there’s an appropriate amount of information to make the diagnosis that we’re getting.

So although a specific level of history exam will not be a factor for 2021. You still need it for accuracy. Just be careful. Let’s not conflate everything to an hour. So my only concern would be, let’s not put ourselves in a position that if your style indicates an hour, I’m not against that, but that’s not an issue where the necessity based on severity is there. So I know this was a quick and easy to show you the new codes that they’re time-based. But I want to say to all of you, the American acupuncture council is here to help you. And I will say, give us a chance to help you. We have seminars, we have a program called the network where I can become part of your office, what I’d like all of you to do. If you have a moment, take your phone, open up your camera and that little QR code in the left side.

If you click on that, you’re going to get a free 30 days to make me part of your office. Give me a chance to make sure your claims can get paid and help you with these codes. Even better realize we do seminars, but network members get a chance to deal with me one-on-one so that we can go through, well, how do I do this, Sam? What do I need to document? What level to make sure that you’re fully compliant. So if you click there, it gives you a three free 30 days to our service. I would say, give me a chance to send me a couple of bad claims. Send me a couple of claims you weren’t paid on. I will guarantee will always make you more money. And after 30 days, you’re going to happily say, I want to stay part of your program.

As I said, this was going to be quick and easy. And it just to give you an idea, but please take a look for those of you that have our Accu code. Remember, these are all published there as well. So the new codes now are going to be more time to base with an elimination of nine nine two zero one. And of course, no time with nine nine two one one. So document your time. I’m going to say thank you to all of you. And I hope that you get a chance to try the 30 day trial, get ahold of me. Let’s get moving forward. Let’s make 20, 21 the best year ever. Your patients need you. I want to be part of that service with you. So I’m going to say thank you to all of you and I’ll see you next time. This is Sam Collins, the coding and billing expert for the American Acupuncture Council wishing you all the best .

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