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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.
That they’re not paying for exams and they’re also still recouping. We’re gonna talk a little bit about that, but we have to update from what we did in April.
Click here to download the transcript.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Greetings, friends and colleagues. It’s Sam Collins, the coding and billing expert for acupuncture, the profession, of course, the American Acupuncture Council. Of course, I’ve got a little update coming up because obviously many of you have been contacting me, network members, and even others have contacted me.
Say, Hey, Sam, what’s going on? I notice. That they’re not paying for exams and they’re also still recouping. We’re gonna talk a little bit about that, but we have to update from what we did in April. So let’s go to the slides. Let’s talk about what’s going on with recoupment and standard episode of care specific to acupuncture and frankly non-physician providers.
So you’ll see here is a letter dated June 23rd from Tri West and it says, we received the above claim. Let me bring it so I can blow it up. And it says. Try West. Receive the above-mentioned claim for your offer. And notice I highlighted and yes says evaluation and management procedure codes are not paid for this rendering provider specialty.
This is the latest thing we’re seeing. It appears, and I’ve seen it absolutely published way that to me would make it more, but it appears they have taken the ability for acupuncturists to be paid. Separate exams when it comes to the va. That of course is very frustrating because of course is an exam necessary thing.
Of course, I to determine the need for care, to determine the continuation of care. So what’s recurring I think is maybe a Leo GE cut here at they’re eliminating the payment for exams. That doesn’t mean you don’t need one, they’re just not. Pay for it. I think it’s probably worth seeing the patient for the overall payments, but they’re not covering it.
We’ll see directly. Now the word that they did this in April, what I’ve seen when their newsletter is not quite clear enough for me. So I’m waiting to see the full publishing standard episode of care, but I’m sure many of you have met. Now. Here’s gonna be the pushback if the exam after April when they published it.
They’re gonna be am behind it because published, however, then I want you all to think of standard episode of Care for Acup Occupy. Whenever you notice the standard episode of care, you’ll notice whether it’s going to be initial chronic follow ups. They include e and M codes. You’ll see really, 9 9 0 2 to 2 0 5 9 9 2 1 to 2 1 5, and I bet pro your authorization has so my argument’s gonna be, they’re saying they’re not gonna cut well, if it’s after April, send an updated authorization, not listed, I’m waiting to see that, then I would say, okay, but if it’s prior dispute’s gonna be, how did you send me an authorization?
Clearly indicates exams and they’re, now, I’m not gonna pay for it. Now, it appears April. This is gonna true. But prior to, it’s gonna be a pushback. Now, is that very frustrating? Of course it is. But I’m gonna ask you, is it worth it to still be part of it? I do, because think of the overall payment on a VA patient.
You’re getting 12 visits to start, probably eight and eight to follow up. Assuming you’re doing three sets of acupuncture and a therapy or two, that’s maybe 110 to $150 of reimbursement. Am I going to take away potentially, three to $4,000 a payment? Because they’re not gonna pay for a couple of exams.
I prefer they do, but I’m gonna say I’m not gonna go that far. It’s something I think though we’re gonna be fighting. I shouldn’t say think. I know we’re gonna be fighting as a profession on a national level along with chiropractors and physical therapists, because this affects them too. Because this goes against the equality provision.
Equality says that if it’s within scope and you pay, other providers have to pay you because this is not Medicare. Now that’s gonna be a little bit of a fight, and that’s not gonna happen in short term. So when you get this, I do think we should dispute it. I would certainly push back if it were pre-AP April, that they should, if it’s after April, not so much.
Of course, if you’re a network member with me, reach out. We’ve got some letters for that as well. But I do wanna highlight also beyond that, just a couple of quick updates. Let’s talk about what’s happening and what’s gone on with doing. Things with 9 7 0 3 9 or 1 3 9, and that’s of course what a lot of offices have used for cupping.
Remember that was removed more than a year ago, so please do not use that code for cupping. It is not appropriate. I. Do not list it. They may pay it, but they’re gonna recoup it. So do not, if you’re gonna do cupping, use 9 7 0 1 6, which is a vaso pneumatic device. It’s not a high payer. It’s about 11 to $15, but at least you are being paid for it.
But again, do not use 9 7 0 3 9 and if they are recouping that, if it’s pre 2024. I would argue they can’t, but if it’s after 2024, they can. Now some people have argued. What about statute of limitations? Statute of limitations, I would argue certainly does apply. Unfortunately, you know what I’ve realized or what I’ve learned, the statute of limitations for the VA is actually six years, so we’re not gonna win on that one as far as this goes.
The other thing here is, and this has come up recently because obviously a lot of you are using pain indexes or similar. To verify how the patient’s improving. I recently had an office, or actually a few that they were denied few further care because they weren’t showing at least a seven point difference on the general pain index.
I really like the general pain index. It’s certainly the similar to the pain interference. Make sure though, if you’re using it. If you’re doing it once a month, there’s gotta be at least a seven point change to be considered significant. Now, most of you, I hope, are getting bigger than seven point changes, frankly, but if you’re not realize it’s going to be a problem ’cause they’re gonna push back, which means you also have to focus in what if I’m using the pain scale?
That also has a limitation, which means it’s gotta be three points or more. Obviously if I say I’m a seven, I go to a six. That means I’m better, but it’s not considered significant. So if they start at seven, the next time you do it to really be considered significant, say on re-exam, it’s gotta be four.
So a three point difference, I would say. Then obviously those two factors are important. If you’re not getting at least one three, you better focus in on something about activity, particularly a home or work activity that couldn’t do before. What they care about is the getting better. Because remember, once they’re stabilized, they have to be on a continua care with flareups.
So keep in mind, acupuncture works well. We need to demonstrate it. Show me on this general PEX pain scale or function, how much improvement there is. Now, this brings me to, for some of you, and I’ve had this question a lot, is being part of the VA worth it? Does it cost anything to join? No. Do the patients sometimes have some hassles getting authorization?
Yes, that’s true. But when you’re paid. Let’s go over it. If you’re getting a standard episode of care for 12 and eight visits, just say the first two 20 visits in a year, considering just the treatment, that’s probably 2000 to $2,500 now, even with taking out exams. Is that worth it to me? Absolutely.
However, am I frustrated with the exam part not being paid? I am. But at the same token, that’s not gonna stop me, but this is where if you’re not part of your state and national association, this is where we need to belong. ’cause this is where we need to push back because how are they treating us differently?
Now the downside is they are doing it to chiropractors. I. To physical therapists as well as massage therapists. So it’s not just you. But at the same token, I think it’s valid to say that it should be covered. ’cause how are you supposed to determine care without an exam because they’re doing this based on a Medicare rule?
Medicare only sets the fees for the va. It’s not the protocol. ’cause if that were true, they shouldn’t pay for acupuncture at all unless it were chronic low back pain and under supervision. So we know that they’re just. Choosing and picking certain ones. So I think we’re gonna have a pretty good pushback, but I do still, it is worth it if you’re thinking, I’m not so sure we are doing next month in August, a whole seminar on the va, what to do, how to make it work for you, make sure you tune into that.
Otherwise, I’m gonna say to everyone, we always want to be resource. If you’re having issues, reach out to American Acupuncture Council. The next specifically, we highlight updates right on our website. And if you’re a member, it allows you to have direct interaction with me via calls and zooms. And otherwise, until next time to my friend, be well.
The one I want to give an example to is, one that’s come up quite a bit recently is what is the difference between 9 7 1 1 0 and 9 7 5 3 0.
Click here to download the transcript.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Greetings, friends and colleagues. This is Sam Collins, your coding and billing expert for acupuncture. The Profession, acupuncture network of course, and the American Acupuncture Council here to always make sure you have the best and latest information. And one of the things I run into all the time in teaching seminars, but also acting as an expert, is trying to understand what are the differences between certain types of CPT codes.
The one I want to give an example to is, one that’s come up quite a bit recently is what is the difference between 9 7 1 1 0? 9 7 5 3 0. So let’s go to the slides. Let’s talk about it. What are these two codes? 9, 7 1, 1 0 is exercise, therapeutic exercise 9 7 5 3 0 is therapeutic activities. What is the difference?
How do we understand that? I wanna make sure acupuncturists have a clear understanding, ’cause that certainly can be within scope. Let’s first get into, we have to always make sure we understand the codes well, to choose the right service. Based on the right code, based on the services we’re providing.
So it says here per CPT that select the CPT code of the procedure or service that accurately identifies the procedure or service performed. Do not select a CPT code that merely approximated. So you can’t say it’s like it. Like I had someone that found out that hot packs aren’t payable by almost all insurances and haven’t been for quite some time.
So he said I’m going to bill hot packs. Infrared heat with the idea being, theoretically any warm body. Emits an infrared portion of the heat spectrum to some degree. That’s not really the intent. Certainly infrared heat is a little bit beyond just a hot pack. So again, we want to be careful of trying to twist things.
If it doesn’t fit exactly, make sure you’re using an unlisted code, which pretty much means it’s not gonna be paid, but use the code that best identifies it. Here we have to remember as an acupuncturist. Can you do more than just deliver acupuncture? Of course, your scope of practice often can be very broad, and I will say certainly look at your state.
If I teach in your state, certainly get a hold of me. We can work on that. Understanding what type of services you can do beyond obviously evaluations, but you’ll often see in your scope it’ll say adjunctive services. The adjunctive services often are very broad. It includes a lot of physical medicine services that might include heat, massage, exercise, and so on.
So do verify your scope. But generally all physical medicine services are generally within scope done with the idea of a traditional medicine slant to it. So let’s take a look specifically at two codes here today. 9 7 1 1 0. You’ll notice as a therapeutic procedure, one or more areas 15 minutes, which means it’s face-to-face time, just like acupuncture and therapeutic exercise Says therapeutic exercise is to develop strength and endurance, range of motion and flexibility.
Okay, so the standard things you do, if you told someone to go out and exercise, what would they think they’re going to improve? I think that’s what we’re seeing with that. Pretty generic, Qigong, if you will, but what about a therapeutic activity? Now you’ll notice the one in the bottom, 9, 7, 5, 3 0 says therapeutic activities, direct one-on-one patient contact by the provider.
So that’s still the same, have to be there. But then it says, use of dynamic activities to improve functional performance. Therein is probably the biggest difference. Exercises generically just to increase strength, flexibility. Therapeutic activities are exercises, but specifically done to create a certain or specific functional outcome.
So 9 7 1 1 0 are movements and physical activities designed to restore function and flexibility. Okay, it. It includes instruction and feedback. So realize when you’re doing this face-to-face, it doesn’t necessarily mean that you’re staring at the person touching them, but you’re supervising, making sure they’re doing it properly, safely, maybe assisting them.
But it does require you be one-on-one. You cannot do exercise with two people at the same time. They can be doing that, but it wouldn’t be this code 9 7 1 1 0 is one-on-one. When you’re with a patient, maybe they’re doing yoga poses, maybe they’re doing tai chi or any type of exercise for strength, flexibility, endurance.
In fact, if you think of exercise generically, it fits almost everything we think of when you go to the gym. Bikes and treadmills, gym equipment, weight equipment, isometric, isotonic, isokinetic, but includes passive things like stretching. Might be assisting the person just in stretching.
So certainly any of that fits. Just make sure you’re documenting what exercises I. How much time you’re spending in doing it. So simple things like knee to chest stretching, maybe a low back rotational stretch, anything like that certainly fits. Notice. These are ones that you might be directing the patient to do.
Now this might be one we probably give them to do it more at home later, but certainly when they’re doing this in the office with you, that is absolutely a billable service. Now, what is the difference of 9, 7, 5, 3 0 exercise? I think we can see pretty easy and straightforward, however. 9 7 5 3 0 says one-on-one patient to improve functional performance.
So this involves functional activities, bending, reaching overhead activities with very specific outcomes to increase a function. So let’s say by example, you had a person that is a grocery store clerk and they hurt their wrist. When you strengthen that wrist, is it just to strengthen or is it to strengthen it to have specific tasks to allow them to do their job at the grocery store?
The same exercise that might be for someone just to strengthen the wrist generically, may be the same for the grocery clerk, but because you’re specifically liking to do a specific task, whether it’s going to be reaching in and out of a bag and lifting items, makes it more an activity. So always think of the outcome, realize all exercises.
Could be therapeutic activities. All therapeutic activities potentially could fit under exercise, depends on the why. So here’s the best way to think of it in choosing it. Look at all these pictures on the right. Could you say to me, oh, Sam, that one is exercise. This one’s a therapeutic activity. We cannot tell from the picture because choosing the code depends on the intent of the task.
So follow me here. If you’re doing abdominal curls, they certainly can be used to strengthen weak abdominal muscles and build as exercise. They come in their stomach muscles are weak. We’re doing abdominal curl strength in the stomach. Great. However, what if the patient is performing the abdominal corals specifically because their abdomen is so weak, they don’t have an ability to rise up from a lying down position or get out of a chair because the stomach is too weak.
Now all of a sudden. Those exercises, yes, they’re strengthening the stomach, but it’s there because we need an outcome that it’s there to perform. Getting in and out of a chair or lying down, that’s the activity and that’s why this is worth more. To give an example, 9 7 1 1 0 has a RVU of about 0.89.
Compared to 9 7 1 9 7 5 3 0, which is 1.15. So you’re gonna see that’s almost a 30% difference. It’s worth quite a bit more because this is designed specifically for that patient, something for them to do, not just generic for everyone. If everyone does the same thing, I’m gonna say, ah, that’s probably exercise.
But best practices determine what is the outcome expected from the task. Is it simply just to strengthen? Or is it a functional performance? When it becomes a functional performance, realize the higher value is you’re designing something specific for this patient’s needs. And I think when you think of most exercises, I think that’s what we do.
Now, obviously if everyone gets the same sheet, the same things, okay? But assuming we’re gonna have some nuanced differences, I think it’s far better to look to make sure we’re choosing the right one, because certainly one is worth quite a bit more. And I want you to be paid what you’re worth. Don’t be afraid to code what you’re doing so long as you document it properly, I will always support you.
That’s what we do at the American Acupuncture Council and the network. To differentiate things. Make sure you have the right resources. That’s what our network does. You’ve been to our seminars, but have you ever thought of, Hey, let’s have an expert on task. I could be part of that. Join our network. We’re with you one-on-one, and you get all our seminars free.
Till next time, my friends, I wish you the best.
Click here to download the transcript.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Hey friends, it’s Sam Collins, your coding and billing expert for acupuncture. You of course, as the profession, the American Acupuncture Council, the network, all of that. We’re here to always support you and help you. And one of the things we’ve had some issues coming up is what about audits? Now that many of you are billing more, you might think, uhoh, I’m gonna be audited.
First thing I’ll tell you is generally you’re not gonna be audited. Very few offices get audited, but we want to talk about when you do what to be prepared for, what do you wanna do preemptively? I don’t want to be reactive, let’s be proactive. So let’s talk about what to do. And particularly if you’re insured with the American Acupuncture Council, they’re really gonna help you.
So let’s go to the slides. Let’s talk about what do you do if you are audited? You’re gonna get that dreaded letter, you’re gonna get it and you’re gonna feel this overwhelming sense of dread. The first thing I’ll tell you, do not panic. You are a good provider. [00:01:00] You’re there offering your best practice of services.
You’re being helpful. Realize that as soon as someone audits you, I’m also upset like, how dare you think? Because what are they looking for in an audit? You often think of, oh, did I do something wrong? You’ve done nothing wrong. Not at all. It just means maybe they wanna look. Sometimes it’s you’re just lucky or unlucky.
’cause they’re gonna look, there’s a certain amount of government oversight that requires that to make sure that services that are being paid are provided. So do not panic. Read it carefully. The requests, what are they looking for? What type of claim is it? Is it personal injury? Is it insurance? Just what type of claim?
That can tell you a little bit, but also take a look at what data they’re requesting. Sometimes they’re just looking at data to make sure that the services were provided. Think of it, if you’ve never dealt with a VA patient in a weird way, they audit everything you do because they require you send chart notes.
You know what they’re looking for in the chart notes. Honestly, just making sure you did the services. They’re not there looking at the necessity as much as people think they’re looking to make sure, did you do [00:02:00] them and is there a decent outcome? Think of what patient or patients they’re looking for.
Often you might just get a one-off that’s just verifying something. If you get several, that could be a little bit more that they’re looking at, but at nothing I would be overly nervous about. Make sure if you’re a network member with me, get in contact with me when you get this. Let’s review it. Let me audit first often.
You’re gonna be just fine. In fact, I’m gonna say nine outta 10 times for most of you. So think of what are they gonna look for when they’re audit? Just your records. So it is important that you document the services you’ve done. Remember, that’s what notes are there for, to tell that story of the patient.
What do they come in with? How did we help them? What did we do? And what was the outcome? So verify. Basically, if what I billed for is on the claim. If you bill for three sets of acupuncture, I hope there’s three sets in there. You build for a therapy or ENM. That’s all it is. In other words, just make sure the services are there.
So when you feel audit, don’t panic, if you get audited by the IRS. You know what I say? Big deal. Did you lie on your tax form? Did you claim something you [00:03:00] didn’t have? Did you not claim income? If they were to come to me and say, Hey Sam, it looks like you donated money, a certain amount of money to the church.
I sure did. Here’s my receipt. I have no panic whatsoever, but I wanna talk about what things can set you up so you can start to be. A little bit preemptive, or at least be aware what is gonna get. One thing that will definitely get you looked at more than others if you bill high level e and m codes.
Now as an acupuncturist, is it appropriate to bill a high level e and m codes? In some instances, it absolutely is. Think of a patient coming in, maybe they’re post-surgical, maybe they’ve got a lot of issues, might that history be a little bit longer? So therefore, these codes can be based on time. So therefore, if you’re using a 2 0 4.
2 0 5, you better document. How much time did I spend the why? Or is it something that’s severe? I’m not panic about it, just make sure it’s done. Now, here’s one area that definitely can, acupuncturist can run into problems. You cannot bill an e and m code daily. And I’ve had offices that billing and go Sam, I’ve been billing it, they’ve been paying it.
I’m like, I know, [00:04:00] but someone’s eventually gonna look and go, wait a minute, this is every day. Remember, the acupuncture code does include. A small e and m code, A little. How are you doing today? So there’s an embedded exam as part of the acupuncture. This is part of the reason we put modifier 25. Modifier 25 is that indication.
It’s above and beyond. Now realize it’s gonna happen sometimes. What if a person comes on Monday with headaches and then comes on Friday with low back pain? I think it’s appropriate for another exam on Friday because that’s different from the headache. But is that common? No. Most often you’re not gonna see them that frequently.
The other is billing more than four services. Now I do think it’s fairly routine for an acupuncturist to do two, maybe even three sets of acupuncture pretty routinely, which means nothing wrong with that. I think that’s reasonable. But think of therapies a the OR two after. Sure. But what if you’re billing like four additional units of therapies?
That’s like a three or $400 visit. That’s pretty expensive. So I think probably not to say never, but realize that might get [00:05:00] you looked at. ’cause they’re gonna just make sure hey, if you’re billing for that many, did you do them? And then of course, just care. That’s long term. Now keep in mind, medical necessity is the least audited factor when it comes to most services delivered by an acupuncturist.
It really is. I’m not panicked about that as much as people think I’m more panicked to make sure were the services delivered. So again, long-term care or extended care for non-complicated, eh, if it’s a flare up, I’m not gonna be as much of an issue there. Just make sure that it’s reasonable. Okay? But here’s one area.
What if a patient makes a complaint? What if you have an ex staff that’s disgruntled because you fired them? Realize, never compromise yourself with a patient or a staff. Make sure everything’s above board, because now if you have not, it puts you in a vulnerable PO position because you’re knowingly doing something not right.
So don’t give that power away. Make sure everything you do there, if someone makes a complaint. So be it. They can complain. Doesn’t make it right, it just [00:06:00] means they weren’t happy. Okay, so here’s something, take an example. Here’s an Anthem policy that says, now just go to the where it says, as part of our own comp on ongoing claims data, we previously contact you regarding your use of acupuncture services.
And they talk about the letter and it says you indicate, you know that you continue to bill outside the expected ranges. This office is billing three sets every time. Is that necessarily outside of the expected ranges? Maybe slightly. I’m never gonna say, don’t do what you think is necessary, because take a look at the second paragraph in the red, it says, we recognize that many factors may impact the coding of acupuncture services.
In other words, they’re letting you know, okay, you’re billing above. Do you have a reasoning why it cannot be? That’s my style. If someone has a hangnail, okay, I would expect not as many sets of acupuncture compared to severe low back pain. So long as you’ve got that in mind, I think you’re perfectly fine.
I have no issue. For me, it’s always about document what’s there. Because by [00:07:00] example, UnitedHealthcare does this quite a bit where they come back and you’ll see here the coding of the acupuncture code 9 7 8 1 3 and 9 7 8 1 4 both indicate not supported. The medical records do not support. 9 7 8 1 3 was performed.
The documentation submitted does not indicate the time spent with personal one-on-one contact, so you’re gonna notice they’re telling you exactly why the time spent and they say it with each code. So what does it mean? I bet the notes are pretty good. In fact, I know they were, but they didn’t indicate time because notice 9 9 2 1 3, they paid that because what does it say?
It’s supported. They also paid the infrared heat because they indicate it where they did it and the severity of the exam. What I will tell you the big issue for most acupuncturists, please make sure you understand. You must document time, face-to-face for each set of acupuncture. Do make sure for audit protection of yourself, where the services reasonable necessary.
I think that’s always gonna be true. But more importantly, does the e and m [00:08:00] code match? And of course, face-to-face time and points must be there. That’s probably the biggest fault I have. Part of that is ’cause I teach at a lot of schools, frankly, and the schools still sometimes fight back on that. Time is not that important.
I don’t care what we think. It’s what the rule says. Please put time. And of course, if you’re doing therapies and you should to some extent, the what, why, and where you did it I think are important to do. And of course, make sure there’s outcome. Here’s the good news. You know why medical necessity often is never an issue for acupuncture because your pain management, and so long as you’re showing you’re making the patient improve or dealing with flareups pretty much a non-issue.
I can tell you if your notes are just average. Not great, but not terrible, but not great if you show a good outcome. Those are great notes. Here’s why. What is an insurance? What is a patient paying you to do? Make them better. Demonstrate that’s always gonna put you in the right position. Good documentation.
Practice helps ensure that your patients receive appropriate care, okay? And from any other provider can [00:09:00] rely on your records to know what was done. Bottom line is. A couple of things to be careful. Remember inducements and kickbacks, that’s where you get issues from your patients. Make sure if you write off their deductible.
That may be helpful to them, but if they’re mad at you, could they turn you into their insurance company for an inducement? They could. So don’t leave yourself vulnerable. If it’s a hardship, make it a hardship. And do remember incident two and supervision of staff? For the most part, acupuncturists do not have an ability to supervise an unlicensed staff person.
Meaning you cannot have just a massage therapist doing something under your license. There’s a few states that do Massachusetts and part in Arizona come to mind, but most states, whatever you do and bill for, you’ve gotta do unless you have another licensed acupuncturist. So be mindful you cannot have someone else do services that also is not an acupuncturist.
Bottom line, keep it simple. Ackman’s razor. Simple answer. A provider can read your notes and identify the service. If you told me I spent 22 minutes face-to-face and I inserted needles into, UB 34 and heart [00:10:00] seven. That would be adequate. Now, you might think, Sam, that can’t possibly take 22 minutes.
It’s not just about the time of insertion. Remember, as soon as you go in the room with a patient and say, hi, Mr. Jones, how are you feeling today? The time of acupuncture starts. So it’s all that stuff that you do leading up to the insertion plus the insertions, plus the removal, plus the counseling is all there.
So that’s what we’re documenting. But the other thing I want you to keep in mind though is what if you get an audit and you’re a little panicky? I don’t know. I’m scared in this way. Don’t be scared, particularly if you have coverage through the American Acupuncture Council. I wanna highlight to many of you, and I’m not sure why many of you don’t just use this one ’cause it’s simple and straightforward, has great coverage.
And you’ll notice here I put the arrows, you have covered proceedings up to $30,000 or 50, depending board defense, audit, defense. They’re not gonna pay the fine, if you will. If you get that, you know what they’re gonna do. Pay for your defense. I can tell you in my experience in dealing with these. We win [00:11:00] 90% of the time because often they’re looking at something, they’re like, oh, wait a minute.
Let’s look at it with another set of eyes. Make sure you’ve got yourself in place to be protected. I’m gonna tell you, the American Acupuncture Council, myself as the network provider is here to support you. We want you to deliver good services. In fact, if you’re not practicing. We don’t have a business.
We are here to support you. We wanna make sure you’re doing the optimum to make your practice successful, which means I work on the money side. If you want to help to learn how to make more money, take a look at the network service with me and I’ll guarantee you’ll be doing better. Until next time, my [00:12:00] [00:13:00] friends.
Click here to download the transcript.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Hey, guess who? It’s acupuncture time. It’s Sam Collins, the coding and billing expert for chiro, for acupuncture for you, if you will, the profession as well as the American Acupuncture Council. I’m gonna speak to you directly as a network service today because a lot of you, and this means those of you who are network members with me, have gotten some letters recently that said, Hey.
We paid you money for the va, we want it back. This is very similar to what went on last year. So I wanna talk about how we can go to dispute this, ’cause I’m getting several of you with some really big requests for recoupment. So let’s go to the slides and let’s talk about what is going on. And this is coming directly from the va, which is VA Community Care.
And again, it’s the care for veterans. You have to be enrolled. And remember, if you’re on the East coast, you will be enrolled through Optum Health. If you are in the West Coast, and now when I say West Coast, let me say Texas and west of Texas, you’re gonna be through Tri West. But it’s happening in both areas.
And what it’s relating to is you’re getting letters that are coming to you saying, Hey, we paid you money. We shouldn’t have. We want it back, pay us back. And if you don’t, we’re gonna take it out of future payments. So we wanna talk about how do you really respond to this, what’s gone on and what we need to do.
Part of it I’m gonna say to you is, this is why I hope that many of you are network members with me, because you would’ve avoided this whole thing had you known. Been part of that. We did go through that last year a bit. So many of you’re getting letters similar to this one. Try West. I’ll leave this one small.
But what this does is it’s just saying the purpose of this letter is to inform you that pricing information, allowable reimbursement on claims previously paid you has been adjusted, given the correct payment is lower. We want some money back in this case, $388. Now that’s not very much, but I don’t like paying anything back.
When I do not have to. So let’s talk about what has gone on specifically and what is the issue that’s happening. How do you overpay it? Let’s face it, fees paid for the VA pay at your state, Medicare allowable. So how could to be wrong? I had someone that sent me a letter and said, Hey, Sam. I went through all my pricing and this is what they paid me before.
How could this be possibly overpaid? There could be two issues here. One of them is called the multi procedure payment reduction, and what this refers to is that secondary services on a claim now I’m not talking acupuncture exams, but therapies by example. If you’re billing a therapy, the first therapy is paid at a hundred percent of its normal rate.
But then each subsequent therapy on the same day is reduced what’s called the practice expense ratio. And what this refers to as the practice expense of a service goes this way by example, let’s say I’m gonna do massage for an hour. I have to do a certain amount of setup for that room. That’s the practice expense.
That practice expense doesn’t have to be done. If you think of it, if I set it up for the first 15, do I reset it up for the next? We don’t. So what they’re doing is reducing that portion of it. Now that practice expense comes out to about 15%, 20%. So it’s not a big amount. Let’s say the code is worth 30.
The multi procedure prov reduction would be that it would be paid probably at about 26 or roughly about 15, 20% difference. So not a big difference, but nonetheless a difference. Now, that’s something they should have been doing and they didn’t, so that’s really on them. My pushback is gonna be at least parsing on that.
However, for acupuncture, the biggest issue is not that, because those would be small potatoes. We’re talking three, $4. It is the use of 9 7 0 3 9 and 9 7 1 3 9. So when you get this letter, what you wanna do is verify with them, how are you indicating it’s overpaid? Is it overpaid because of the procedure reduction portion or is it being overpaid because I use 9 7 0 3 9 and 9 7 1 3 9 for cupping.
Please be aware. Since February of last year of 20 24 9 7 0 3 9 and 9 7 1 3 9, were no longer part of the standard episode of Care for Acupuncture, which meant you could no longer use it. I’m hoping some of you go, oh yeah, I remember when that happened, and you were no longer to use that code. Now, of course, if they were allowing it and they were.
Prior to this change 2024, they were allowing you to bill 9 7 0 3 9 for cupping. And frankly, many of you were getting paid 45 to $50 for it. So if someone’s willing to do that, I’m willing to take it. However, let’s keep in mind, let’s think about that logically for a second. Cupping is a much simpler service than acupuncture.
Yet you are getting paid more for cupping than acupuncture. So you can look and go that doesn’t make sense. However, because they allowed it, I’d say, go ahead. Technically, you should have not been using it after last year. Realize here is the newest list of codes I. Allowed for acupuncture with the standard episode of care since February of last year, and you’ll notice immediately none of the 9 7 0 or 9 7 1 3 9 7 0 3 9 or 9 7 1 3 9 is included.
They were removed. Now the pushback that I have, if you’re getting a request for a refund, that was prior to February of 23 for the date of service, the standard episode of care, up to that point. Did include it. Therefore, it would be appropriate for them to pay, and the pushback would be, hey, it was allowed at that point.
Now, if you are getting requests after February 23rd, now that’s a whole nother issue. That’s one that, oh, shucks, we should have known. Now, network members with me, you should have well known because I sent out a lot of information. This is why I’m sending this all directly to you as well, not to mention just for everyone, let’s make sure you understand.
If you’re billing the va, these are the codes they allow. They do not allow 9 7 0 3 9 if you are wanting to do a service that is not on this list. You must specifically get authorization from the VA to provide it, or it’s automatically non-paid. Now I will have you notice. Notice the last two codes in each one, the 0 5 5 2 T, and S 89, or excuse me, 0 5 5 2 T is the code for laser.
So they do cover laser. Don’t get excited. It doesn’t pay that much, but it is covered. So bottom line is do not use for cupping any further. If you have been. 9 7 0 3 9 or 9 7 1 3 9. Do not use them. They’re gonna be a problem. And if you get paid, you’re thinking I got paid. They’re gonna come back and take it back.
I. We’re gonna push back on that a little bit, but again, after February of last year, it’s gonna be a little bit harder. So for cupping, what should you do? I’m not saying not to bill for cupping, I’m saying for the va, however, it is only under 9 7 0 1 6, and that code, frankly, is worth between 11 and $15, which truthfully makes much more sense to me.
I don’t think cupping should have the same value as acupuncture. Not to say that cupping doesn’t have value, but is it as much as doing the needling? I think not. So therefore, yes, it’s still payable, but just under that code. Now, if you’re getting issues on the price reductions, that’s what I would still push back on, depending on when they’re implementing.
But remember, that’s gonna be a pretty small amount. If it’s a big amount, I’m almost certain it’s going to be cupping. So make sure you’re pushing back. How can I dispute it? The number one dispute I have, and this is the starting point, but I want always there to be two disputes, is just plain statute of limitations.
Let’s face it, we have only 180 days to bill the va. Does that give them infinite time to recoup, years later? No. Under federal statutes it’s 365 days or one year. Therefore, if they’re making a request to recoup money from you, that is over 365 days or one year. That’s the number one pushback. If you’re a network member with me, please contact me.
We have a dispute letter to that fact for you already formatted that you can send. Hopefully this is encouraging. Some of you, oh, this is why that network is so good anyway. If you’re not a network member, you’re just gonna have to go back and say, Hey, that’s statute of limitations. I would also push back though on this issue case law, there’s case law that’s been around since the nineties that says when an insurance pays something improper and the provider has not done anything.
To make that payment improper. The carrier is the one responsible under federal rules. They may push back on that, but if you recall last year, we were able to dispute that, but I’m expecting the same. So my hope is that given in another month or so, we should see some pushback where they’re going to no longer seek these recoupments, at least the ones prior to 23 or over a year.
My concern for you though, is make sure you understand, do not bill. 9 7 0 3 9. I know you’re thinking they paid me. They can recoup it. We wanna push back. Let’s make sure the claims are correct. If you’re not a network member with me, this is a great time to understand what we do. This is something we’re trying to get you ahead of the curve and not chasing after it.
VA patients are still very good patients. Remember, we got about a 20% increase in the Medicare fees for the first set this year, so that’s a good patient. Just understand the rules. Again, no use of cupping. If you’re not a network member, please take a look. If you’re a network member, please contact me.
Let’s go through. We can do a one-on-one zoom if we need to, but let’s make sure we’ve got some fire to push back on this. Until next time, my friends, I wish you the best.
Click here to download the transcript.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Greetings, everyone. This is Sam Collins, the coding and billing expert for acupuncture for you, for the profession, for the American Acupuncture Council, and of course, for my AAC network members. Let’s talk about, have you really decided, how do I determine
Have you ever thought of what the costs are? As most acupuncturists, you’ve probably dealt mostly with cash and you’re charging one fee no matter what you’re doing. I want to start to do something that allows you to make more money in your practice by identifying your services and creating a true value to them.
I can’t tell you how often I’ve had acupuncturists come to me and say, Charging a fee that is well below what people will accept. By example, if someone is willing to pay you 70 for a service, but you only charge 35, how much are they going to pay? 35 is what you charge. And I say this really from an insurance standpoint, because if an insurance is willing to pay you 70, but you only charge 30, they’re going to pay you 30.
So have you ever really taken some time to look through your fee schedule to understand the value and what we’re going to focus in on what’s called relative value units. So let’s go to the slides. Let’s talk about that. Every single service. In CPT, any service you can provide as a licensed acupuncturist to a patient, that service has a value.
And that value is just to compare one service to another. By example, if one service has a value of 1 and another service has a value of 1. 5, It tells you the one that’s 1. 5 would be 50 percent higher than the other. So what I want you to do with this is start to really use just your fee for acupuncture.
If you tell me what you’re charging for your first set, I will tell you what the relative price should be for everything else you should do. And I’m going to implore my network members, in particular those that are viewing this, Make sure if you haven’t reached out to me this year to do so we can go through with you on a one on one Zoom on Establishing and understanding a fee schedule that’s specific to your area.
There isn’t generic across the United States It depends on your area. So I’d like to start this though with all of you taking a look at what is your current charge? Have you ever really thought what do I charge for stuff? I want you to write this down. What is your charge? For the first set, an additional set of acupuncture.
We’ll just choose manual for now. Keep it simple. What is your charge for a 99203? A simple mid level new patient exam. As well as 97124. Just simple massage. Nothing fancy. So acupuncture. mid level new patient exam and massage. How did you choose the fees? How do you know what one should be to another? What we’re going to focus in on is the relationship of one to the other.
Now, what we’re going to start with is what is your fee for 97810? Now you may think how do I come up with that? There’s things to do there. And again, network members can contact me about that, but I’m going to just keep it simple. What do you currently charge? If you tell me what you charge for a 97810, I will tell you what the other fees will be and what an insurance will pay.
Give me what an insurance pays for one code, and I’ll tell you what they’ll pay for any. Now I want to keep in mind, a lot of your managed care contracts don’t necessarily follow this. But, this is one of the reasons I don’t like managed care, but things that don’t. By example, workers comp, personal injury.
Even the VA follows this because I will tell you the VA and Medicare rates are much higher than what you would get from American Specialty Health in a lot of these. So I want something that’s going to make sense. So what this is about though is understanding the value of services. So on this page I’ve given some examples of the relative value units for common codes and you’ll see right in the middle I’ve included the acupuncture codes.
And you’ll notice 97810, 97811 all have relative values from one to the other. To make this the simplest way to think of it, if you charge 138 for the first set, I’m just making it an obvious example, what should be the cost of a second set? 80. Now you may think, wow, that’s a big, yeah, there is more than a 50 percent difference.
between the first set and the additional set. The first set includes more of the initial part of the visit, all the exam part. That’s why it’s a little bit more. And I’m going to warn everyone, this has gone up 20 percent this year. If you’re not aware, and you’ve probably seen it within the VA for those that are billing, there is a 20 percent increase in the relative value.
RVU’s updated substantially because I think they really looked at the cost. and value of acupuncture in relation to other services. So 97810 and 97813 both increased 20%. So if you have not increased your value of 97810, I’m going to let you know you’re losing money. Now, the value differences of 11 and 97814 did not change, but those two increased substantially.
By example, on a Medicare slash VA patient, That is literally 10 to $15 more per code. And remember that’s based on a $40 rate. The $40 rate for 9 8 9 4 0, which was fairly common, is now 50 plus in most areas. So start to look at that. But what this also does though, is give the relative values of other services by example.
Notice simple heat, infrared heat, 9 7 0 2 6. It has a value of 0.2. So if you think in relation to a 9, 7, 8, 1 0, you’re gonna think my goodness. That’s literally around 15 percent of that. So if you want to know the relative value of a heat lamp, it’s about 15 percent of the price of your acupuncture, which means that’s why it’s worth like 10.
I, in addition here, though, I have other codes, 99203, 3. 37. Now here’s something to look at notice 97810 is 1. 38. 99203 is 3. 37. Now, this is not exact, but what we all see here, that’s close to, if not quite, three times that rate. I’d say about 2. 6. What you want to start to think of is, what should be my price of a mid level new patient exam?
Two and a half to maybe 2. 75? Of the value of the acupuncture code. So if I’m charging, say 60 for a 97810, my price for a 99203 is going to be 160, 170, somewhere in that range. What I find often is a great deal of undervaluing. of the services. So here’s how we’re going to do this. Let’s talk about what you charge.
Let’s just make it simple. What if we were to charge 75 for a first set of acupuncture? I’m just using this as a random number, so that’s what your fee is. Great. I take 75 and I divide it by its relative value. So I take 75, divide by 1. 38, and it gives me this conversion, which is 54. This conversion number then is what we multiply any other code by.
To tell me it’s relative price. So if my first set of acupuncture is 75, notice the additional set 5434 times 0. 79 means 42. Now I’d probably round that up to probably 43, but needless to say, you can see here. Oh, okay. It’s not going to be the same price. I’ll give an example. I had an office that was charging 60 for every set, and they were paying in full for each one.
They’re thinking, this is great, Sam. You know what that told me? If they’re willing to pay you 60 for an additional set, do you think you have undervalued the primary set? You bet you have. So I want you realizing that this swings both ways, that you really want to start to have a reason behind the fees.
And again, with network members, I want to push you that. Let’s start to set this up, because here’s what I’ve learned. Most acupuncturists bill roughly 8 to maybe 10 codes on a regular basis. Exam codes, acupuncture codes, a handful of therapies. I find of that, usually more than half are undervalued. Which means Half of the codes you bill, you’re getting less money than you should.
So by example, look at the exam price. Now again, remember I said it’s about 2 point whatever above, but notice 54. 34, 183. So again, not quite three times, but you can see the range. But notice for massage. Massage has a higher value than the additional cent. Hence why that one is going to be 49. 99 or again I’d round up to 50.
Now to show you how this works, here is the fee schedule for Arizona. And I just picked Arizona. Obviously this is going across the U. S. and I have network members everywhere. Network members contact me, we’ll go over what’s in your state. But this is always a good starting place. This is the Medicare rates.
for the state of Arizona. And every state has this same breakdown. Now what I’m showing here though is the Medicare rates notice for the acupuncture codes, exam codes, but let’s do the math here to show you how RVUs work. Notice the value in Arizona Medicare is 43. 86. By the way, last year that was like 35.
It’s gone up substantially. So I take 43. 86, I divide by 1. 38. It gives me a conversion of 31. 78. I then take that number, 31. 78, multiplied by any other codes RVU to give me the price. Now notice how this works. 31. 78 times 79 is 25. 10. Do you notice the fee for 97810? 25. 17. I know it’s off a few pennies, but you get it’s in that range.
Notice 3178 times 3. 37 for 99203, 10710. Notice 99203, 10695. Again, within 15 cents. 3178 times 0. 92, the value of a massage, 2923. Notice the value of massage. So you may want to start to realize that, oh, this is exactly how insurances do look at fees, particularly when it comes to personal injury and non managed care.
Now here’s what’s further interesting. My general rule is An office probably wants to be maybe twice the Medicare rates as a typical fee. Now, I’m not saying necessarily that high But that’s a starting point. I would say maybe even 1. 5 But here’s where I bring this up in Arizona for workers compensation and let’s face it.
Would anyone say? Oh, yes, the workers compensation fee the mandated fee is the highest fee in the state No, it’s not but notice the conversion in Arizona is 68 So instead of being 3178, it’s 68. So think of it 97810 has a value of 1. 19. If 68 is your first, or you’re going to use 68 conversion, the worker’s comp rate is going to be, oh wait, 68 times 1.
19 is about 120 percent of that. You’re thinking that first set then is going to be around 80. Yeah, what would the additional set be? 68 times 79 or 80 percent of that take off about 13. Again, right about 52 or 53. Please be careful of undervaluing. If you are billing 50, And a carrier is willing to pay 80, but you bill 50, you’re going to get 50.
So be mindful that if someone ever says, how did you come up with a fee schedule? Have a real reason Not based on what my friends have been doing. We don’t know what your friends are doing. We’re right. Your mom told you that Did you ever get away with it when you said that’s what Johnny did, mom.
Mom’s not going for that. We don’t care what Johnny does, what we do at my house. So network members, I’m mom right now. I want to know, what are you charging? We can go through it. Make sure you set up a zoom for that. I want you to really start to realize, make a competent fee schedule, not a guessing fee schedule.
And that’s what too many of you do. And that’s why a lot of acupuncture struggle. I want to end that struggle. By setting up a good sound fee schedule now bear in mind when you sign a contract With an insurance company you’re accepting the pay less. That’s why they like you to sign up By example, if you sign up with UnitedHealthcare, what do you get?
About 60 a visit. What if you don’t sign up with UnitedHealthcare, what do you get generally? About 100. Same might apply with Cigna. Now ones that are HMOs, maybe we want to, but others you may want to rethink it. So to help you do that, what I’d like you to do is take a moment, and this is, this is not just for my network members, obviously this is for everyone, Use this QR code.
Go in here. You’re going to send us some information of what is your fee for 97810, where they’re going to send you back the calculations of the codes that we just showed you based on your fee for 97810. See if it makes sense, but I’m going to warn everyone. Be careful if you have not increased the value of your 97810 this year, you have flat out lost money because it went up 20%.
That doesn’t mean all managed care, but for everything else. As always, we want to make sure that your practice does well. Network members especially, I’m going to emphasize, if we haven’t done our meeting this year on fee schedules, get in contact with me. Let’s get moving. For everyone else, make this a good starting point.
Maybe I’ll see you in the fall for a seminar to make sure you really can make sense of it. Or how about this? Join the network. Make me part of your staff. Let’s work one on one. As always, everyone, I’m going to say thank you for taking some time with me. We always want you to be successful because your strength is ours.
Take care all.