Let’s talk about what is going on with UnitedHealthcare. I’m sure many of you have received or have seen the letter that indicated about what changes you have to make.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Hey, greetings everyone. It’s Sam Collins, the coding and billing expert. American Acupuncture Council and specifically the American Acupuncture Council network members. And I’m really appealing out to you as well. Not just that we’re not sending it to everyone, but I wanted to keep you updated on what’s new and changing.
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As we always promise, we want to make sure you get the information first, have the right information, can use it. I know a lot of you have probably gotten the UnitedHealthcare information about, we have to build differently and put the GA modifier. I wanted to help attempt to make this simpler, more easy to understand, and kind of.
Boil it down a little bit. So let’s go to the slides. Let’s talk about what is going on with UnitedHealthcare. I’m sure many of you have received or have seen the letter that indicated about what changes you have to make. I want to make it even that much simpler. Here’s what’s happening. Beginning February 1st.
So starting this month, they want all acupuncture providers must bill UnitedHealthcare for all services they’re providing, even if the services aren’t covered. Now, for the most part, let’s be realistic. Probably you’re billing out mostly acupuncture. There isn’t a lot of services that you’re doing that aren’t covered.
But let’s just say there are services that you’re doing that’s not covered. They’re saying now they want it to be billed. So they want these non covered services to be billed, even if they’re not payable. And this will make an added step from what you normally have been doing. Now, keep in mind, the added step is just you’re going to add it.
The reality is, the No Surprises Act, as a lot of you are familiar with, which has been a couple of years, requires that all providers make patients aware of what their costs are. I think acupuncturists have always done an excellent job of that because that’s the number one question every has is how much is it going to cost?
So what this means is you’re going to make sure not only to do that with patients, make sure what they know, the cost are what’s covered and not covered. But more importantly, what’s not covered. We have to make sure the patient’s aware, like by example, if you’re doing cupping or moxibustion, you want to make sure to let them know, okay, this cupping service is not covered.
And therefore, it’s 25, whatever you charge. So again, think of it now, if it’s a therapy, therapies are for the most part covered, so it’s going to be the services that are not covered. Remember, contract and so forth will come into place. If you’re contracted and it’s bundled, it will be. So again, this is going to be services that they normally do.
Do not cover and the patient will be liable for it’s not going to be very many, but there may be instances where this come up. Realistically, this is should be something you’re already doing. Of course, every patient should be aware of, okay, if your insurance is going to cover, what is it going to cover, but also what is it not going to cover?
So therefore the patient understands what they’re having to pay. That’s again, part of your financial agreement. I hope you’re all already doing that to some extent. Now, what does this mean for non covered services though? I’m going to tell you for the most part, I’m going to look at things that are unusual.
Obviously, massage, manual therapy, exercise, heat, those are all covered. But services that aren’t covered, I’m going to put in cupping and moxibustion as being the most likely. Those are ones we’re going to have to outline. Now, by chance, let’s say the policy doesn’t cover therapies. They’re not bundled, then you would include therapies as well.
But for the most part, I’d say they’re covering therapy. So again, non covered services. And what does this apply? And this is where people are confused because it says commercial plans. So you’re wondering what’s a commercial plan? You know what a commercial plan is one that a person buys or they get through their job for the most part, you know, they get as part of their employment.
The only place that doesn’t apply is ones that are called self insured that are just managed by United healthcare. These would be. big giant employers, you know, large union groups and so forth, which aren’t that typical though. Obviously, if you work with a lot of people in those, you might run and cross it, but it’s going to be generally the commercial plans.
One patient’s purchase themselves, get through their job and Medicare advantage plans, but it doesn’t include if it’s self insured. So it is worth asking when you’re verifying. Is this a self insured plan? Because if it is, then you don’t have to do any of this. Again, I don’t see this as very hard. What do we need to do?
We need, oh, did I hit the wrong button here? I apologize. What we need to do is to make sure a few things. Number one, when verifying UnitedHealthcare, inquire if the plan is a commercial or Medicare Advantage. If it is, we have to do this. Now, again, I’m going to emphasize, this should be something you’re already doing.
You should already be making the patients aware of cost and what services aren’t covered But this is now something they want a little bit more detail for them You’re going to complete a financial understanding with the patient with an estimate of cost which means your cost So let’s say you charge 25 for cupping you would indicate this cupping service is not covered and you would indicate something as simple as It’s not covered because it’s not part of your plan.
Your plan may not consider it medically necessary, but anything like that, the bottom line is make the patient aware it’s not covered and they’re paying out of pocket because in order to hold them liable, the plan now is saying their requirements to do that. It says there identify if any. If any are not covered and include a statement.
So some services are going to be covered. Your acupuncture is covered, but services that are not identified and simply again, state it’s not covered or may not be covered. What you’re doing is making clear. You’re not promising them that it’s going to get paid. It is non covered. Now this brings up, what if you’re doing acupuncture and the acupuncture is not covered, you would do the same for that.
I don’t believe we’re billing too many like that, but just in case, then what you’re going to do is bill for those services. Now in the past. We’re pretty much never required to bill for services. They weren’t going to cover. They’re just liable to the patient now What they’re wanting is that we do bill those services to the insurance What we have to do uniquely though is bill it and then put modifier G a so that’s G as an apple Or excuse me G as in George a as an apple and what you’re doing with that is simply indicating that the patient has signed a waiver meaning that financial agreement where they’ve agreed They’re responsible.
What this is really doing is putting in place that patients are never going to be surprised They know what it’s going to cost in addition the insurance now when you bill in this way They’re going to send the EOB back to the patient indicating what they’ve paid for But that service such as cupping like nine seven zero three nine or one three nine would indicate as patient Responsibility and at the fee you’ve charged and remember that fee is the fee you want to charge It’s up to you.
That’s your cash rate. Whatever your fee is and the patient’s paying. That’s all you’re putting there So is this a little bit of a hassle? Yeah, I think so Um, it’s only a hassle in that we need to bill it. Everything else is the same You still have to inform patients you’re doing a service not covered You start to make sure they understand the cost of it.
Now the only difference is that we also have to put it on the claim and when we do so just put it with the GA. So let’s say it’s a therapy this this plan doesn’t cover a therapy. Okay, we would indicate that therapy with modifier GA. Keep in mind it’s not required for services they pay for. This is only for services they’re not going to be paying for.
So they’ll process it and then they’ll indicate patient responsibility. So let’s kind of get back at synopsis here. Let’s go, what’s going on? UnitedHealthcare commercial policies for acupuncture. You are now to make sure a patient is fully aware of services that they’re going to cover, but also not cover.
That’s not different. We’re to make them aware of the cost of the services, whether they it’s covered or non covered, which is also not different. So therefore that’s all going to be the same. That’s something I think acupuncturists do a good job of. Haven’t you always made sure your patients know the cost?
This is just making sure it’s memorialized, if you will, the patient signing it. And now we’re going to bill it. With a GA, if it’s a non covered service. So just a GA. Now you might be saying, well, what type of form do I have to have? It’s going to be a pretty straightforward, simple financial agreement.
Where you would indicate, these are the services we’re being provided. This is the amounts. And here’s the cost. And also indicate if it’s non covered. Now if you’re a network member with me, AAC Network, just contact me. We do have some samples. If you’re not a member, I apologize, but that’s not available to you.
That’s why we do the service. At least you’re getting the information. But for those that are members. get in contact with. We have a couple of examples. It’s not that complicated, but want a straightforward statement that the patients know it’s not covered. Here’s the point. It protects us. Therefore, a patient can’t come and say, I thought it was gonna pay.
You’re gonna point out. No, we said that at the beginning, and so I think it eliminates a lot of that issue. However, there is an extra step. Yes, you’re gonna now have to put everything on the claim. Part of what United Healthcare is stating they want to see the services that are being provided. What my hope is is that they start noticing that, wow, this cupping service is popular, moxibustion, maybe it should be something that we’re covering.
At least that’s what I would think. So, that’s the change. Non covered services, make sure patients are aware they’re not covered, the cost, put them on the bill. Patient still responsible. Nothing crazier than that. Again, if you’re a network member, get in contact with me. If you’re not a network member, the whole reason I’m doing this is to get this out to our network members, though it’s going to everyone contact me, let’s get you started on into the network.
We’ll give you a lot more help. In addition to that, though, we can give you a day to day help as well as forms and other things. We’re here to help. So for all of you, I greet you and say thank you for listening for a few minutes. I hope to see you at a future program as well. Take care.
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I always want to keep you updated first of the year on what’s changing, what’s new, and there’s been things that are changing for this year regarding telemedicine.
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 there friends, it’s Sam Collins, the coding and billing expert for acupuncture, the American Acupuncture Council, and most importantly, you as a profession and as an individual provider. As always, we want to make sure you have the most current information to make sure your practice is thriving. And actually just making more money, if you will, or continuing to make more money is our hope.
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I always want to keep you updated first of the year on what’s changing, what’s new, and there’s been things that are changing for this year regarding telemedicine. Now, I know you’re thinking, is telemedicine something that we do a lot of? Maybe not, but I want to point out there’s going to be a place for it.
So I think it’s important to know what these new codes are. So let’s go to the slides. Let’s talk about telemedicine for 2025, because there was a whole new brand set of brand new set of codes in the old system. And when I say old system for 2024 earlier, when we built telemedicine, it was always for. E& M codes.
And then we build with a modifier 25. That has changed. For this year, they’ve updated. But let’s make sure first that we define what telemedicine is. Let’s make a clear definition. Telemedicine means that the provider uses interactive audio video telecommunications between you and the patient, which means literally a live visit.
It’s just audio video. That’s all just live. So in other words, it is a face to face visit. It’s just a face to face visit done online. I think that’s very viable in this day and age. And I think, though, that really started during the pandemic. I think it’s really stuck because we’re going to move that way anyway.
Think of how often with a medical provider, This is going to save a ton of time because how many of us have been to a medical provider? They don’t touch you. They just sit on the other side of the room. Shoot We should have done that audio video better for everyone. That potentially could fit for us as well in certain circumstances But do remember it’s live audio video and here’s probably the bigger Sticking point for many of you because you’re thinking oh good.
I’m gonna do herbal consults across the nation I’m going to, I’ll slow down. You have to have price, proper licensure. And it says here, make sure you are licensed both in the state where you are located, obviously, but also where the patient is located. So by example, if you’re in California and you’re trying to do a telemedicine visit for someone in Texas or New York or someplace else in California.
You not as a licensed acupuncturist. Now, this is irregardless of if you’re billing insurance, frankly, because you cannot practice in a state you’re not licensed. If you’re saying you want to do some type of herbal consult outside of your state, you’re not doing it as an acupuncturist, you’re doing it as an individual, which means you have no protection.
You’re not, you don’t have malpractice, something goes wrong, it’s on you. I’d be very careful of that. The key factor here is, I think if you’re going to do this, do it for patients that are here because Maybe they have difficulty coming in. Maybe your first visit is going to take an hour because there’s so much information you’re going to do a long consult with them.
Telemedicine might bridge that, so that way when they come in the office, you can get right to it. And or, maybe they don’t have that much time. What about a patient that goes I can’t get off work until this time, I can’t be there. Okay, let’s do some of it, telemedicine. So here’s what’s changed for 2025.
We have some brand new codes and you’ll see these codes. It’s 9800 through 98007. And what these are for. is telemedicine, but you’ll notice they are E& M codes. You’ll notice it says, Synchronous audio video visit for the evaluation management of a new patient, which requires a medically appropriate history and examination.
Straightforward in nature. That’s literally the same thing as an E& M code, except it says synchronous. So in other words, think of these just like E& M codes. 9 8 0 0 0 will be a 9 9 2 0 2, the next one a 4, 0 5. And so much the same way, and I think the easiest way to see these is it’s going to be based on time.
A 15 minute audio video visit, 9 8 0 0 0. 30 minutes, the 0 1. 45 minutes, 02, 60 minutes, 03. And I do think you want to caution that it’s not always going to be about medical decision making, though it could be, which exams mostly are. But if you’re doing a telemedicine with a patient and it takes an hour because of all the information, is it appropriate to use 98003?
Absolutely it is. So don’t be afraid to use it, but document it the same way. You’re going to document I spent one hour over audio video. Tell me the system you use. Tell me the date and time, but you don’t record it. You don’t have to save it somewhere. And it’s going to be all the information you take.
And it’s going to be the same stuff you would take down if they were sitting in front of you. Their history. And maybe some of the evaluation. Now when I say history, realize that’s going to include past history, family history, review of systems, all that stuff. But can it include some exam things? I think at least some.
Could you do potentially a tongue evaluation over audio video, get it close enough to the tongue? Probably. I’d be worried about color a little bit, depending on the cameras, but I think we’re okay. Could you certainly do a range of motion? I think so. Now, could you do tongue and pulse and body palpation?
No, but I think this visit often is going to be one based on a lot of counseling, a lot of history and information. So these are new patients. And these are established patients. They work the same way, just about time. I think time is the more likely use. Here’s the difficulty. How much has this happened in your practice in the last year?
If you’re saying none, it’s probably going to happen none this year, because I think we have to promulgate this. I would say, let’s say you have a patient, they’ve had a car accident, they’re coming in from a medical referral, and you talk with them and you say, hey, we’re going to have to block an hour. for this.
And the patient, Oh, I don’t have an hour. I don’t have an hour until I can come two weeks from now. I don’t want to wait two weeks. Let’s do an audio video. Let’s start there. Now you may wonder what is the value of these? They’re much like the value of a regular E. N. M. They’re slightly less. And by the way, next month we’ll do a program.
The program I do will be on our views. So we’ll go over that. But I’m gonna tell you, it’s roughly 80 percent of what you would build your normal E. N. M. S. There’s no modifier necessary because there’s no treatment. It’s just this visit and what if a visit where the patient’s calling and just goes, you know what?
I need to discuss with you. I’ve got these issues. This visit could be counseling. These could fit. I would just be mindful. Make sure it’s a plan that covers exams. Here’s one of the problems we’re having for acupuncturists. A lot of the plans that you have joined as a provider, you wind up getting into a contract that says we don’t cover exams.
Now, that doesn’t mean you shouldn’t do them. They’re just saying they bundle it and don’t pay it separately. I know a lot of you know what I’m talking about. That’s an upcoming show as well. Anyway, what my point is that be careful. If they’re not covering an E& M code, they’re not going to cover this.
So it’s got to be a plan that covers an E& M, but I do think this is reasonable in some instances. Realistically though, let’s talk about acupuncture. While I love the availability of this service and the potential to use it, I think there’s a place for it. Is that the way we really want to treat someone?
Is that how we’re going to make them better? Let’s face it, in acupuncture, what you do is hands on. You get in the room, you put in needles, because without needles, you can’t talk me into feeling better. Sorry, give me some advice. But the reality is it’s the acupuncture, it’s what you do, but this can be a bridge.
So focus really on the acupuncture part, but this bridge might work for some, I can tell you major carriers, Anthem, Cigna United Healthcare, they will cover this. Just, again, go back to wait a minute, what does my contract say if I’m part of ASH? Maybe not. Now, there’s also new codes for 2025 for telephone calls.
Now, I say telephone calls, actually, what these are called are synchronous audio visits. Now, the reason I say telephone calls is because I’m old. Young people think, no, I don’t need a phone. You can do it through lots of devices. And so realize, though, it does mean just audio only. Now, these work in the same way as the old phone call codes.
And let me be clear. Remember those old codes for phone calls that you had? 99441 and so on? Those are gone. They don’t exist. But let me be conscientious when it comes to a phone call. Phone calls aren’t very typical. Because phone calls are difficult. A phone call that results in a person coming in for a visit or has been seen within the previous 7 days.
is one that they’re not going to cover. And so make sure we understand that. But they are straightforward. 15 minutes, 30 minutes, 45 minutes, or an hour. Okay? That’s a new patient. We have telephone audio visit here for established patients. You know where this probably works though? You have a patient you’ve treated.
It was two weeks ago. They call you and go, oh my god, it’s killing me. And you spend 30 minutes on the phone and they can’t come for the next month because they’re going to go out of town. That could work. Now notice the scenario I gave because if the result of this phone call is a visit is being appointed, then it becomes part of the visit.
So phone calls aren’t going to be well paid because let’s face it, no one’s going to call. You’re going to go, Oh, just do these acupressure points. I’m not saying you won’t do that. Chances are you want to get them in for a visit. So I point this out because it’s important to know, because you’re going to hear people saying there’s codes changed.
And it’s true, but we have to look at what’s the viability of use for us as providers. Is it really viable? And I would say for most of these, in this sense, probably not. It even applies to this new one, which is called a virtual check in. I had someone the other day as acupuncturist, that’s why I decided to do this.
I want to use this code because the patients are sending me emails. A check in is not an email. A check in is when you have an electronic health record system. That’s protected HIPAA compliant, where the patient logs into their account and then checks in with you with some information that maybe you’re communicating back and forth.
You can tell now, that’s probably not viable. One, I don’t know of a system that’s out there for us that does that. Some medical ones do, but the ones for accus, I don’t see that too often. I’m not saying if you have one that does, great. The problem is going to be, notice it says, provided within the previous seven days or procedure within the next 24 hours.
So in other words, if the result of this is again, treatment. Or, was within seven days of a prior visit? Does not count. So being mindful here, when it comes to use of these, do they really match? Because chances are when someone does a check in or a phone call, what is it going to result in? The person coming in for a visit.
So let’s be careful of being overzealous, but focus in on what we do well. What is the reason that people come to you to receive acupuncture if you could talk them into feeling good? You would have done that already or they wouldn’t need to see you It’s the acupuncture where I think this is helpful is to understand that there can be a bridge Particularly the audio video one that helps the phone call thing or you know The audio only is what I think it helps to get them in the office in that few minutes of counseling though You’re not billing for it directly Indirectly, it’s creating that good patient doctor relationship.
They trust you and you’re giving them solid information. The good news is, your practice continues to thrive. Next month when we go over RVUs, I’m not sure you’re aware, do you know your fees for the first set raised 20%? And that’s where I want to make a focus. So as always, we want to be the place where you get the right information.
The American Acupuncture Council has a very vested interest in all of you. Please make sure you continue to practice well, but I also want to make sure you’re profitable. If you’re not already, go to our website for the network. Take a look there. We’ve got a lot of information to always keep you updated because as always, your success is ours.
Until I see you next time, be well, my friends.
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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.
Happy New Year and greetings to my friends and colleagues. This is Sam Collins, the coding and billing expert for acupuncture, the American Acupuncture Council, and more notably, you and the profession. I’m here to help you to make sure that you get information that keeps you up to date and moving and there’s nothing better to get knowing what’s going on than let’s get ready for 2025.
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So let’s go to the slides. Let’s talk about are you ready? for 2025? Are you really setting yourself up? Realize this is that first week, so everyone’s back in. Let’s get things ready. Let’s be proactive, not reactive. So the first thing I will tell you to do, you want to start thinking if you’re doing any insurance, but for that matter, even cash, we’ll get into it.
Are you prepared? For insurance, I would say prepare for understanding What’s going on for plans in 2025? Is anything changing? It’s time to go back through to see what’s new for certain plans. Now, keep in mind, if I have one person that works for a company and has insurance A, another patient that comes in from the same company with the same insurance, I don’t have to go through all of that if I do one thorough way of going through that policy on one person, so long as everyone has the same policy.
So the first thing I want to look at is, What’s going on with deductibles? Has there been any changes for 2025? Did it increase, decrease, stay the same? By example, though acupuncturists don’t directly bill Medicare, you’re involved now. The Medicare rates, of course, did make a nice increase. We’ll get into that.
But the Medicare deductible did go up 17 to 257, which means if Medicare went up, might other plans. Yeah, that’s a hit and miss, but check. One thing I’ll point out though, that a lot of times acupuncturists are not familiar with, however, is that deductibles may roll over, meaning that they will not have a new deductible at first of the year if that person saw a doctor in the last quarter, and what this means is, let’s say by example, you don’t go to the doctor at all.
You’re a patient, and in December you go to the doctor, you have a $1,000 deductible, you have to go and you meet that deductible. Then January 1st sits and you’re like, oh my God. I gotta pay the deductible again? I just they don’t punish someone in that way. Most plans will have some type of rollover for a person who’s seen the doctor within the last part of the year.
So it’s worth checking. Often that may not be the case, but it’s worth looking into. So I would check to make sure. Most importantly, We want to know deductible so we can make patients aware of what they’re going to pay. And keep in mind, we also want to check on not just deductible, but what’s happened with any coverage.
Has there been any changes to the benefits? Is the acupuncture benefits better, worse, or the same? By example, a lot of people have said, Sam, I heard that the Medicare Advantage Plans were getting rid of acupuncture. They were not. So long as the person has the standard one that has what we call gosh, I gotta think of the term, but it’s where you’re going to have just a acupuncture benefits that are there all the time.
Realize all plans under Medicare have the regular benefits, meaning, MD supervision, but for those that have routine acupuncture, it will cover for pain management. Look to see if any of that’s changed. Many of them may or may not have it, so always check. Don’t assume. Regular Medicare did not update.
You will still need for regular Medicare Part B medical supervision. Do check though, because this is something that’s occurring with some of these Medicare Advantage plans and others, is the requirements for pre authorization. Many of the Medicare Advantage plans continue to have it, but the ones under United, at least some of the plans, and others under Humana, will require pre authorization, which means they all allow you to do the first visit, but then you have to request more after that.
Not that it’s that hard, it’s all online, but it’s just something to know. You don’t want to bill out assuming it’s being paid and they later say, oh it requires pre authorization, because often they will not do a retro authorization. So do check to make sure what are the coverages, what are the changes, are the number of visits the same.
Are they combined with anything? Is there any limits? And this is something to keep in mind. The limits to acupuncture benefits under insurance are limited to what are they covering under the diagnosis they allow. By example, Cigna has probably a 500 code list of things they cover. Aetna has a list that’s about 25.
So you can see clearly one more that’s going to have a little bit more or possibly more. So know what those plans cover. Don’t assume. Some plans will cover fertility. You want to check to make sure it does it. And here’s my point. Get as much information about beforehand so we can make sure that we understand what’s going on with what are we going to bill and how we’re going to be paid.
Because one thing to look at is what’s going on for fee schedules for this year. And I want to talk about just your common CPT codes. I don’t care about things you don’t do. Most acupuncturists, of course, are going to do exam codes, E& M codes. Acupuncture, of course. And then maybe a handful of therapies.
What I care about are those codes. Here’s some really good news. The relative values For the first set of acupuncture, both manual and electrical have increased substantially. For most of you, if you’re billing the VA, this literally means you’re getting about a 20 percent increase in that allowed rate.
That’s pretty significant, which means that may roll over into other plans because plans that use Medicare, which include VA, Personal Injury Work Comp, et cetera, will be increasing. Now, the downside to this, of course, It’s not going to affect your ASH. It’s not going to affect your Optums. Now, if you’re part of ASH, certainly if you’ve been in a while and you’re a tier six, I will be looking for, have I done a protocol to ask for a raise?
That’s something to be thinking of, but do take a look and think of, wait a minute, how much it’s increased. Now be careful. Relative values tell you what to charge from one code compared to the other. So I want everyone to start a little bit differently. Literally, you’re going to see a large increase. in the first set.
If you want to get more details of that, I’m going to tell you. Come to our seminars with the American Acupuncture Council right at the end of the month. Keep you updated there. If you’re a network member with me, just get in contact with me. I’ll get you set up. But really, this is a significant difference for you, particularly when it comes to things that are related.
VA, of course, but everything else related, which is going to be and so forth, which means prepared to understand. W for this year? What type do we have in place? Make are always aware of your think of what’s the numbe ask beyond if you can hel
Make sure you get something new for the year. Now, if someone’s on an ongoing care plan, they started in December, I’m not concerned, but someone coming in new this year, always have them sign a new and updated financial agreement so there’s no surprise. That’s why we have the No Surprise Act. Make sure they’re aware of what their costs are going to be for what services are covered.
And maybe some services that are non covered. By example, on some ASH plans, they don’t cover massage, which the patient can be charged for. Therefore, we got to make sure they’re aware of it. The bottom line is, just like for you, if you go someplace, you want to know the cost, make sure your patients are aware of their cost as well.
Which means, are you doing anything financially with How do you set up properly for a cash discount? Outside of California and Minnesota you got to be very careful. They allow some big differences but for most states you can make a 5 to 15 percent so if your rates raise up that should be the same thing for cash.
But what about prepays? I do think prepays should be something that every office offers. I’m not going to say it’s absolute that every patient’s going to want one, but I’m going to tell you some patients are. And it’s a good way of creating another revenue stream because people can see it as affordable.
And remember, prepays allow you to discount more than a 5 to 15%. Now what about your assignment of benefits? Remember, patients need to sign a new assignment in the new year. They want one up to date. If you’ve not seen someone in a long time even, Make sure they’re signing a new assignment. What is the assignment?
That just tells the insurance company, pay the doctor. This is something many of you may have gotten letters asking you about that for the VA. Not a big deal. Should always be on file. I would just make it at first of the year. As patients come in, they sign a new assignment January 1. Which means we’re always offering compliance.
Our compliance when it comes to HIPAA. What have you looked there for a while? Have you seen, is my privacy notice up to date? Does it have everything that I do? Which by example, Almost everything is open. What if you say, Hey, I want to make phone calls to remind you about appointments. There’s nothing wrong with that, but in order to do because that may not be private, the patient has to give permission that, oh yes, you can call and leave a message, because that line may or may not be private.
So keep that in mind that if I’ve not done anything to update, have I looked at it? Do I have all the things in place? Do I have business associate agreements? Who am I working with, whether it’s a billing service or an electronic record company? Are they all HIPAA compliant? They should be, but make sure you’ve got things in place protecting ourselves.
Now, what about your office policies? Things that you do in the office. There’s nothing wrong with updating those. And I would say two things to look at. Do you have a no show policy? Some offices like to have those. If a person doesn’t show up, do they get charged? Outside of the VA, you may do so do keep in mind, if you have a no show fee, make sure the patients are made aware beforehand.
What about credit cards? There’s nothing wrong with obviously taking credit cards, debit cards, but can you charge extra? You can, but let’s be careful. It’s not a percentage. You could have a fee that says, if you choose to use a credit card, there’s an additional 1, 2, 5 transaction fee, depending on the amount.
Now, and what I mean by that is, you’re going to charge 5. If they’re only charging 15, that seems a little steep, but what I’m getting to is having a fee. What it has to be a separate from the charges. You can’t say the more you charge, the more of the fee, but there could just be an allowed rate.
That’s allowed so long as patients are told beforehand. Make sure, of course, too, you have consents on file. If you’ve not seen a patient in a while, if you’re seeing them from, an ongoing plan from, November, December to now, I think we’re okay, but if they’re coming in with a new care plan, they need a new consent.
Okay? Make sure also that you have the difference between covered versus non covered. Okay? The patients know what is covered, but what is not covered, I want to make sure they understand that’s going to be out of pocket. They’re going to understand that. I want to make sure if we’re doing cash or prepay, the compliance is we have things on file so that no patient comes back and says, I’m upset because I don’t feel it was fair.
Now you may think I never do insurance. I’m not worried about that. Realize. You can get complaints and other things from the board based on this if a patient makes a complaint. Put things in order. Have them to make sure all the agreements are there. And do remember, it’s always documentation, whether it’s going to be financial agreements or what you’ve done for treatment.
And again, I don’t care cash or insurance. If it is not written down, it didn’t happen. So make sure the documentation has what’s going on. A quick review of what you done. You know what a SOAP note is? The S. A review of the chief complaint. and how the patient is changing as a result of care. Is it better or worse?
In other words, it’s what they’re telling me, subjective. The objective is, what did you find? The tongue was coated. The pulse was wiry. There’s muscle spasm, loss of range of motion. And then your assessment is nothing more than your diagnosis. And then from there, your treatment. So for acupuncture, and this is the area we run into the most problems when we deal with audits.
Remember, if you have insurance through the American Acupuncture Council, you have audit protection. So if you’re audited, they’ll help defend you, but it’s hard to defend because if you don’t document what you’ve done for acupuncture, please make sure you’re documenting the time you spend face to face with the patient, as well as the points of each set.
And remember that 15 minute, or if you will, 8 minute rule that follows. If you’re doing therapies are fine. Just make sure that the therapies are documented properly. What am I doing? Where am I doing it? You can’t just check off if I did infrared heat. But tell me, oh, I did infrared heat to the lumbar spine for 15 minutes.
Again, not very complicated, if you will, but document it in a way that it can be seen when what was done. And again, if it’s timed, make sure time is there. When you’re doing an exam or E& M code, are you making sure that if you’re billing a 99203 or a 202, is that clearly the value? A 202 would mean that you spend at least 15 minutes, a 203, 30, or at least one complaint or multiple complaints with strain and sprain.
Make sure that if you’re billing a code, know why. If you’ve never attended a seminar with me, I’m going to encourage you to go, what is the requirements for E& M? I think a lot of times people really misunderstand that. And I’m going to emphasize time. Acupuncturists do spend a lot of time. Document it.
There’s a value to you. That’s getting you prepared for 2025. Document what you’ve done and ultimately the patient getting better. Your practice thrives off of people understanding and having access to you. The understanding Is this going to help? Then they come in and go, wow, that did. There’s a value to that.
Make sure people understand that. For me, the biggest difficulty for acupuncturists is getting yourself out there. Being prepared for 2025 would be, if I have back pain and I’m looking for an acupuncturist, how am I going to find you? Have you set up a network of people that refer? Does your website do it?
Does the signage in front of your office when I pass by, does it let me know what’s going on? Practices thrive based on, of course, patience. And we thrive based on you. We’re here to be your resource. The American Acupuncture Council, of course, more than the malpractice side, I deal with the network side.
We’re here to help you. One on one, a resource. By example, are you aware of what’s happened with the fee schedules? I’ve given you a little bit of that. What about new codes for phone calls and telemedicine. That’s changing for this year as well. It’s more than what we could do in this short time, but I just want to make you aware, be proactive, not reactive.
I look forward to all your success. I hope to see you all at a future seminar. Until then, my friends take care.
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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.
Greetings, my friends, members of the network, and all of you. It’s Sam Collins, your coding and billing expert for acupuncture, really, and for you in the profession. I always want to make sure you’re successful, because quite frankly, you’re not. We have a vested interest as a company. The American Acupuncture Council not only does malpractice and all that, but we do continuing education and do services to support you because we’ve learned.
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If you’re not well supported and it’s successful, you don’t need what we’re selling. So we want to make sure that we’re symbiotic. I want to begin starting for next year, getting to be proactive. So let’s go to these slides. Let’s talk about what do we need to do for 2025. And I’m saying it’s going to be proactive 2025.
And the reason I’m indicating that it’s got to be proactive is because too often acupuncturists are simply reactive. Something happened. What we’re going to do as a network director, if you will, I get a lot of information well before often you may see it. So one of the things I would encourage you to do is always be around AAC network to know what’s happening, what’s changing.
So let’s talk about what’s going to change for next year, but how do we really become proactive to keep our practices successful and the things you want to do with that in mind, what I want you to think, start to think of is for 2025, what is going to be my practice success? How am I defining it? What does that mean?
Is it a certain number of patients I want to help? Is it a certain monetary figure I want to hit? Is it going to be getting to just simply more people? There’s lots of ways to define it. I don’t want it to always be about money, but part of me says that. I’ve learned that you really have to make sure that this is a business.
And you do have to have a business mindset. Certainly you want to care for your patients. That’s primary, but there’s got to be payment for it. My goodness, everyone can treat someone. But what if you’re not getting paid for it? How do you continue doing that? So I want you to think of how do you define your success?
What does that really mean? And when you get there, tell me what you start to realize are some of the barriers if you look at how did I define success last year? Was it going to be for this coming year? What things stopped me from getting there? What are the barriers? What can I do a little bit better?
Because if you are not growing even a little bit, your practice is failing. Because if you grow a little bit, you’re just keeping your head above water. You have to grow just to keep your head above water. Remember economy, 3%, 4%. If we’re saying inflation may be higher, so you’ve got to probably do at least 5 percent better just to be at where you were this past year.
In fact, I’ll say maybe you’re sinking a little bit. So what are these barriers? How are people coming to the office? Is the barrier one that people just are getting to you? Is the barrier because people can’t afford it? There’s all types of things, but you want us to think of how do I. One of the barriers I think often is people are not sure what you do.
So have you created something that people know if they looked at your office, what you actually treat? Too often acupuncturists will go, I do acupuncture. What does that mean to most people? Nothing. Define to them what it means for you. I can help you with headaches or sciatica or anxiety or depression or whatever it is.
Because that barrier is often they’re just not knowing. Of course, a big barrier is always going to be money. www. circlelineartschool. com So we got to start to think of how do I make sure that I create value to what I do. Notice I didn’t say cheaper. Cheaper is not always necessarily the way people choose a doctor.
I’ve never chosen a doctor because it was cheap. I’ve chosen it because I felt there was enough value. If it’s too expensive, of course, no, but be careful. Always follow something I’ve always held true. People buy. what they want and beg for what they need. You’ve got to put yourself in a portion where, yes, they need it, but they want the care.
You’ve got to make sure that you’re creating that type of value. So what is your model? Have we set up a model that where if people are looking online, they can find me? If they’re needing to, what’s my cost? Is there a way of figuring that out? Oh, that’s affordable. That seems reasonable. Are there, pay plans and things I can do?
So start to really lay down that pattern for yourself to say, how do I want to start to make this work for next year? It shouldn’t be by hook or crook. Write some things down because at the end of the day, it really makes a practice successful no matter how you think of it. Even if it isn’t money, it’s about patience.
Helping people. But when they come in, how do they come in? Are they cash patients? There’s three types. Someone pays straight cash. How about a person that gets a discount if they pay cash? Or how about you offer so called prepaid plans? That kind of modern acupuncture style where it’s Multiple visits bought at a cheaper rate.
Realize that’s one of the ways that you can help it more affordable Is by doing that. If you’ve ever attended a continuing education seminar with me, we’ve talked about that. But how about members that are with me one on one? We have a network where, as you’re a member, we can get into it. How does it work for your office?
What’s specific to your state? By example, what if you’re in Montana? We have to have a escrow account. Other states, you may not. Is there any limits? But I think it’s something that we should all explore because always I think a barrier is money. Are there some ways we can help that? I think so. One of the ways and barriers is when people have insurance, let’s face it, do people go to the doctor more often?
Here’s a good thing for all of you to do. You may sit back and say, I don’t want to take any insurance. I agree. I don’t want to take any bad insurance, but I’m not going to turn away insurance that pays me. And I think that’s where you’ve got to start to think differently. Realize and ask your friends.
How many of your friends, how about yourself, have gone to the doctor and pay cash? And then, your answer is no. But then you expect everyone else to do it. Now, I’m not saying there isn’t a part of that, but I want you to realize, when you ask most people if they’ve been to the doctor and used insurance, it’s going to be 99 percent of them saying yes.
So you want to start to think of what some of these are better. Obviously people who have the good, standard, high level insurance with small deductibles, those are great. For But those aren’t common. What about PPOs? That’s the very common one, but here’s one thing to keep in mind. A PPO, do you have to join?
By example, and I’ll give you three. UnitedHealthcare through Optum Health, Cigna through a SH, and Aetna, often used through a SH or sometimes secure, don’t require an acupuncturist to be in network to be paid. You may not be aware, but when you’re out of network on these plans, even though it’s a PPO, oh wait, preferred provider, that means they can still go where they want.
Do you know they get paid more? So before you join something, check to see whether or not it’s exclusive. Non exclusive plans, I won’t join unless somehow it’s much more attractive because can you live off of a 40 visit? Maybe you can’t. What about an HMO? That’s the ones that are strict. They only can go there.
That’s that strong ASH, but is it worth it? My general rule is an insurance has got to pay at least what would be my cash rate. And if it doesn’t, I don’t think it’s worth the work. So if you belong to these, know that, okay, I can make it work because I can be efficient. It’s difficult for acupuncturists though, because unlike a physical therapist or a chiro that can use an assistant, you can’t.
Everything that’s billed you have to do. So all of a sudden now that makes that barrier tougher. So maybe that is one you shy away from. But what about health savings accounts? How many of your patients are even aware they can use their health savings accounts in an acupuncture office? Many aren’t.
And they’re going to go, oh, I didn’t know, because you didn’t tell them. Same would apply with, have you ever thought of, could I treat people in an auto accident? Outside of Florida, you can. These are great patients, they’re hurt, need your help. It pays really well, it pays the real fee schedule. By the way, have you ever thought of working with other providers, like an M.
D.? That you become their pain management person. Do you know they’re looking for you, because what do M. D. ‘s do? They refer. What about auto cases? What about workers comp? In many cases, you can be the primary provider. Have you ever checked into people being aware that they can see you? My goodness, in California, an acupuncturist is considered a physician in the work comp world.
But how about the VA? Have you ever thought could I be part of that? Is it worth it? I think so. It doesn’t cost anything to join and you get well over a hundred dollars a visit. That sounds like a really good patient with no co pays, but have you ever ventured? And even if you belong to the VA, how do people even know you treat the VA?
You see where I’m going with that? Often people go I treat VA patients. How do I know? I drive by your offices that says acupuncture. Are you doing anything on your social media? Any way of marketing? So when someone looks up, I’m hurting and I need to, care for pain and I’m in the VA, does your name pop up?
Is there anything on your site that would direct them there? Remember how Google works. It takes information and scrubs from different sites. And if your site has that information, your name is going to come up. By the way, if you were to Google acupuncture, coding and billing seminars and programs, I’m first.
My company is first. You know why? We don’t pay for it. But we have so much data out there because we want you to be successful. So make sure people are aware. Now, what if you treat Medicaid? I’m not a big fan because it doesn’t pay well in many States pays horrible, but some areas can pay better. So it’s something that’s worth looking into.
There’s some areas in New York, quite good. What about Medicare? And you’re going, oh regular Medicare Part B, still the same thing, chronic low back pain only with MD supervision, so not great. But what about Medicare Advantage policies or plans? Now, I’ve heard some people going, I heard all the plans aren’t going to have that new or the routine acupuncture.
Not true. It’s no longer automatic. You want to start to check. I will tell you what the plans are doing. I can tell you UnitedHealthcare is still going to have routine acupuncture. The only difference. is it’s going to limit it to 30 visits per year. So it will still be available, but you do always want to check.
Does a person have that benefit? So at the end of the day, it’s about patients getting in your office. And what is it? That’s the bottom line. Have you ever thought of if I join ASH, I’m getting 40 a visit. Does it make sense to me? In many instances, it may not because I want you to start to think of what does it cost to treat a patient in your office?
Have you ever actually thought of that? What does it actually cost me? I want you to do this by taking your overhead, all your related costs. By the way, I would include your student loan payments as part of that. I really would. And then you divide that by the average patient visits you get per month.
So let’s say you add up everything your rent, your, cost for gowns, needles, and so on. And that total is 4, 000. And you see about 25 patient visits a week or 100 visits per month. That means you’re getting 40 per visit. So if that were the case, let’s think of that for a second. If I’m treating an ASH patient and it’s one of this 100, you’re making 2 for that visit.
I don’t think that’s worth it. I don’t think you could survive on that. Now, if all of a sudden you go Sam, because I’m seeing ASH patients. I can see 200 patients a month. That drops to 20. Okay. But here’s the difficulty. How do I increase it 200 or double it? Keep it in mind that most acupuncturists are treating most people for 30 minutes, sometimes more.
There’s a limit to how much you can do. So you got to be careful of devaluing your service and falling into the trap of some of these plans by looking at really what you’re getting. Now, if you told me, Hey, Sam, I joined because I get 10 extra patients per month. Which means, Hey, I’m getting, 10 visits.
Maybe that’s going to be about four or 500 extra or more. Okay. I like that. It can’t be the bulk though. It’s got to be a value add, like taking up a spot that wasn’t already filled, but I’m not going to trade a high paying patient for a lower paying patient. So you really got to start to look at doing a fee schedule review.
This is 2025 proactive. When was the last time you made an increase in your rates or for that matter, have you ever looked at. Having your rates make sense. Understanding what is the actual value. What is the cost in my area? What resources do you have to figure out what is in my zip code? This is what I do for my network members.
Members of the American Acupuncture Council network service directly with me. It’s one of the things we do. We do a fee schedule review and we talk about, let’s talk about what’s going on in your zip code. I don’t care what your friends charge. Because they probably don’t know what they’re doing either.
I want to look at real charges. I want to start to look at what we call relative values to understand true fees. Because I find often acupuncturists devalue probably three quarters of the services they bill just getting less money. Because I want you to think of when was the last time an insurance company raised rates they allowed?
ASH has it in years, but what about other plans? I don’t think it’s so much worrying about how much have they raised. Some don’t, and it may stay stagnant for a while. But how many of you are aware that you’re billing below what they allow? I’ve seen this happen. An office bills something for 30.
The plan allows 50. Now, if you call them and say, do you allow 50? They won’t tell you, but there’s ways of figuring that out. But anyway, if you bill 30 and they allow 50, what are they going to pay you? 30. So I’d like you to start to take a look at understanding relative values. Have you ever reviewed your rates based on that?
This is federal government. This is not made up. This is what a service costs based on something else. So what you can do is start to tell me what some one thing cost and i’ll tell you what other things would cost based on the relative price of that one. So by example, this is how you would use relative values.
Let’s say by example, you said, Hey, Sam, I charged 60 for a 9 you know, for a set of acupuncture manual. Great. I’d say that’s fair. Is that very high? No, that’s probably about 170 percent of Medicare, give or take. So needless to say, if I charge 60 for that, what’s going to be my fee for my second set, third set?
Or what about other therapies? And this is where I find a lot of discrepancy. Okay. I’ve seen people charge the same amount for first and second set. Makes no sense. The additional set should be 50%, 15%, or excuse me, 30 percent lower than the primary set. So let’s give this example. If I bill 60 and insurance pays me 60 for the first and the second, you know what this tells me?
I’ve way undervalued the primary. Because if you bill below, they pay it to you. But if you bill above, they’ll reduce. So by example, let’s use this. If I take 60 as my fee. And again, this is if you’re saying, Hey, Sam, I know 60 is fair. It’s what I charge. Good. Let’s base everything on that. The value of a 97810 is 1.
15 relative value. So I take 60 divide by its relative value and it gives me 52. 17. Now this multiplier is what insurances do. And they take that number. And then they multiply it by the RVU of every other code. So by example, to give you a way to look at this, Medicare allows about 33 to 37, depending on your region for this.
So what we’re going to do is take 5217 multiplied by the RVU of the additional set of 0. 85 gives me 44. So notice 60. And then I would round this up, by the way, make it 45. But you’ll notice, oh yeah, Sam, that is about 30 percent different. In fact, it’s exactly 30 percent different. But here’s where I find it’s often the biggest misnomer.
Notice the exam price. Relative value is 1. 15 for 97810. Notice the relative value for 97, or excuse me, 99203, new patient mid level exam, 3. 35. Will we all agree that’s approximately three times the rate? Not quite, but close. So if it’s three times the rate, notice it’s 60 here, 174 here. Notice three times the rate.
I can’t tell you, at an office last week, that was charging 75 for this. That literally meant, yeah, you’re losing 100 when it comes to this. What about things like massage? Massage actually has a higher value than does an additional set. Not by much, but notice the value is 0. 91. So that means massage is 47 compared to the additional set of 44.
Please make your fee schedule make sense. If you’re a network member with me, it’s time to get ahold of me. Let’s do our one on one Zoom. It’s part of your service. Let’s take care of that because you weigh under value. If you’re not a member, it may be time to join and start to go, wow, I’ve really messed this up.
And I find that to be often true. Start to really look at a fee. Now, I’m not going to be against you saying, Sam, I chose this fee for a specific, if you’ve got a reason, of course, but is the reason when that’s bad business. Remember, there’s a time for you to put your business on Shark Tank. Is this really viable?
Here’s an unfortunate statistic for a lot of acupuncturists. Generally, close to 50 percent of acupuncturists within five years of graduation no longer practice. Now, I don’t think it’s for lack of understanding the business of acupuncture as far as how to treat someone, but not how to make a business out of it and create value.
Some people do that really well. My goal for any acupuncturist, by your third or fourth year of practice, you better be making 250, 000. You’re going to go, Oh, that’s not that complicated. If you start to understand where patient values are. So I want you to do these things for 2025. Please take a look at any plan changes of anything that you normally have billed out.
Start looking now. Don’t wait. Start to look now. A lot of things can be done online. What’s changing? As I mentioned, a lot of people said, I heard there’s change to the Part C plans. Please read more. Please make sure, make your patients aware that if the existing plan they have doesn’t have it, there’s probably choices for them to have a new one help them do that.
Realize that time is coming up. December, I believe, 7th is the last day for them to change, so make sure your patients are made aware. What about deductibles for next year? I know Medicare is going up to 254, and you’ll say big deal. But that means other plans may do that, but keep in mind, what about deductibles?
Sometimes deductibles, if the patient has used their insurance in the last three months, That may fall into the next year. What about Assignment of Benefits? Many of you have contacted me saying, Hey Sam, I had an Assignment of Benefits thing came from OptumHealth and TriWest regarding my VA patients.
What is an Assignment of Benefits? I don’t understand. Or they’ll use the term AOB. The Assignment of Benefits is something that you need to have current on file. It’s what directs the insurance company to pay us. It’s block 13 of the 1500 where it says please pay the undersigned provider of services. By doing that, you get the check.
If the patient’s already paid you in full, leave it blank. Why I’m bringing this up is that VA wants a new one every year. So get in the habit, new year starts, patients sign a new form. That way there’s no confusion. They understand, yes, payment’s coming to you. They should, of course, because they’re not paying directly.
But that applies, I think, to other consent forms. I know you may have had the patient sign a consent to treat, but what if it’s two years ago, a year ago, and it’s a new plan of care? Have them sign a new one. Don’t leave any risk there by not having a patient saying I didn’t sign a current one. Have it re signed for the new year.
Same would apply with financial agreements. When the new year comes, make sure people know, here’s what the cost is, here’s how we plan to do it, and here’s what we do. If you want to, we also offer a prepay plan. Or we offer some other type of discount for time of service. It’s not very large, but something that can be there.
Make sure patients are aware because that’s the barrier. What does it cost? How about credit card fees? Have you reviewed that? Look at your credit card fees. They’re often higher than people realize. Now, what can we do about that? It’s part of doing business. However, businesses are allowed. to disclose there’s going to be an additional fee for use of a credit card.
You just have to do it before you do it and tell the patient, if you choose to pay with a credit card, there’s an additional 3, 4, 5, whatever the fee you charge. That fee can’t be based upon the amount of purchase, by the way, but it simply comes down to a credit card transaction fee. I think that makes sense.
And of course, the other thing, please review your fee schedules. I’m going to suggest you may want to do it with an expert like me, but at least do it with some level of semblance of information. Realize in many states, what they’ll do is they look at the Medicare fee schedule, which by the way, will update in early 2025.
By the way, network members get in touch with me. I’ll keep you updated there. And start to look at a percentage of that. Realize that many major health insurances, such as Anthem, use 1. 75 of Medicare. And I will guarantee most of you, you might have one or two services, 1. 75 of Medicare, the rest are probably not.
So keep in mind, often I find for offices, they’re losing 10, 20, maybe 40 a visit by not understanding the value. Now you might say Sam, I belong to this plan and they cut the fee. I get that. But that’s something you signed up for. And that’s what I want you to start to think of in that review. Is it worth it?
Realize the American Acupuncture Council is here to help. This is our website, our phone number. We’re the resource to help you get paid and understand the coding and billing. We do lots of courses for continuing education and network members get those for free. So I’m going to suggest let’s make a good 2025 by having a proactive plan.
I hope to see you all soon. Take care of my friends.
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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.
Greetings, friends and colleagues. This is Sam Collins, your coding and billing expert for Acupuncture, the American Acupuncture Council, the American Acupuncture Council Network. But more importantly to you, your success is ours. We’re always here to try to make sure that you have all the best available information to make your practice thrive.
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I want you to be the best possible provider and focus on that. Allow us the chance, the Council, to be that support service for you, where we’re there to help you with all the nuances. That’s what network members get from us. But let’s talk about today’s program. Let’s talk about when you see a policy that says they get 25 visits.
What does that really mean? Or when it says we have 40, 80, or whatever, what about some plans that it’s actually unlimited? Does it really mean that? So let’s go to the slides. Let’s talk about this when we get policies that tell us the amount of visits that someone has. What does it really mean when a policy allows 25 visits?
Does it mean they get 25 automatically? That no matter what, I hope all of you are going, well, no, that’s probably not true. What we have to have every time is it has to be medically necessary. It’s not going to be just an automatic. It’s going to be, should it come up as something that’s necessary? In other words, if a person says, I feel fine, I feel perfect, but I want to get my 25 visits.
Will the insurance allow that? And that’s where we have some difficulty because when patients have policies like these, they have the false pretense that, Oh good, that means I can come two times per month this whole year and the rest of my life. Now, as much as I would love that to be true, that isn’t always medically necessary.
So we do have to keep in mind that we need to learn to navigate and achieve the optimum utilization, make sure patients are aware. Now realize, many people have conditions. Pain and otherwise. That could require some acupuncture services that will max out those visits and could be that way, but we have to make sure, do we have it medically necessary?
Is it automatic? Does it mean they get to use it at their discretion, two per month? But what about maintenance? Will that be covered? Well, first we have to think of what is medically necessary because in order to have 25 visits, you’re always going to say they’re looking for medical necessity, something that is necessary for the patient.
And that must be delivered with defined, reasonable, and evidence based goals. Now, realize As an acupuncturist, there’s many things you can treat beyond just simple what I call the physical therapy chiropractic side, which is musculoskeletal and pain. It can go beyond that, but we still have to have evidence of the changes.
It must be based on the patient’s presentation of their diagnosis. Make sure it’s a covered diagnosis. That’s probably going to be number one. For a patient to be covered for acupuncture, you have to find out what are the covered diagnosis. By example, Aetna and Cigna have very similar covered diagnosis, but there are many more with Cigna than with Aetna.
But what about Blue Cross Blue Shield? So it’s sometimes learning that nuance. This is what we do for you at Seminars, of course. So make sure we have the diagnosis, but then also, what is the severity? What are the clinical findings that demonstrate the need for care? It says, continuation of treatment is contingent upon progression towards defined treatment goals evidenced by specific significant objective functional improvements.
Notice it says here, outcome assessment scales, range of motion. The good news is, pain, which is the number one thing acupuncturists treat, is always going to cause some dysfunction of some type. Their function is going to be less based upon their pain. So talk about when a patient says they’re having pain, even if it’s headaches, what is this headache causing you to have problems with?
Oh my goodness, I couldn’t work. I can’t work more than 30 minutes at a time. We’re had to take a day off. All these things demonstrating some type of evidence of a functional change. I think acupuncture works very well here. Think of how many types of doctors you can see, but how many can you treat with that when you leave the visit, You literally feel better.
I mean, if you go to a medical doctor with a headache, and I’m not saying this is a negative, what is a medical doctor going to do? Evaluate you and make sure it’s not nothing more severe, but then otherwise give you a script for pain medication. They call it in by the time you can get the prescription filled, hours later, maybe the next day, then you take it by then.
Maybe the headache was gone on its own or it can help. Someone comes to you with a headache. How many of you have witnessed what I call the miracle of acupuncture? that they leave going, Oh my God, I cannot believe that worked. I’m without a headache and I came in with one. That happens all the time. So we want to demonstrate that the patient has changes.
So always rely on how you document as demonstrating the number of visits. Cause 25 visits are certainly reasonable. If you can show they have a headache after a certain number of visits or time, the headache is gone or reduced. Now, can that headache return? Absolutely. So it’s not a never ending. It says certain conditions require to be co managed by a medical provider.
If you’re dealing with, some plans cover addictions, strokes. Cancer related. Well, those you’d want to be working with them. By the way, I took this directly from Cygnus coverage and it says, medically necessary services including monitoring outcomes with progress and change in treatment, with a withdrawal of treatment if the patient is no longer improving.
I mean, let’s face it, how many patients are going to continue to come to you if you’re not helping? This is the hard part because patients start to understand the value. and necessity of care. Our job is when do we demonstrate that that care is no longer medically necessary from an insurance standpoint.
I think so long as we can demonstrate there’s ebbs and flows and we’re showing improvement or can be supportive, I think we’re going to be on the right track. Just be careful. Maintenance or non covered means it’s intended to improve or maintain general physical condition. I don’t disagree with that. I think certainly healthcare should be part of that, but that’s not what our insurance is for, is it?
Insurance says Sickness or disease. So it’s not about keeping you healthy. I wish we would no longer call it health insurance. We should call it sick insurance. It says maintenance acupuncture services when significant therapeutic improvement is not expected. So it’s maintenance when it’s not expected.
Now that doesn’t mean it has to improve every time. So when someone says there’s 25 visits during that 25 visits, if we’re noticing a continuance of improvement medically necessary, the difference is, How do we demonstrate it? Are you using outcomes to do that? Are you giving me the true objective changes?
Don’t tell me or rely on the patient feels a little better. That’s certainly not going to be adequate. That’s part of it, but they feel better. How? What functional change? What objective change do we have? It says services that do not require the skills of a qualified provider, such as acupuncture, are limited to that can be practiced independently and self administered.
So in other words, if you’re just saying we’re coming in and just doing exercises. only. They’re going to say, well, why couldn’t they continue that at home? So you always want to show that it requires a skill, meaning they’re getting true acupuncture services. Home exercise services can be formed safely and independently.
It can’t be just that. Now, should exercise be part of the care plan? You bet. But I want you to keep in mind, when I go to an acupuncturist, you know what I want? Acupuncture. Chances are we’ve tried exercise. Now that doesn’t mean you’re not going to give me some better ones. And I’ll say doing Qigong type exercises, if you will, or physical therapy type, or just gym type are all helpful.
and could be part of it, but the thing that separates you is going to be the acupuncture. So keep in mind, there is something though that insurances will cover, particularly on some of these visits, what they call supportive care. And it says supportive care can be referred to as ongoing or long term treatment or care, and it may be necessary as treatment for individuals who have reached maximum benefit.
In other words, they’ve reached maximum benefit, but you notice right after you withdraw care, They begin to have a significant drop off. Now, what we want to do, make sure we’re showing, because of that drop off, they’ve been doing home exercise. They’re doing things to help prevent it, but it doesn’t do it.
So, you want to demonstrate that the patient can get ongoing improvement. with the care. When it falls off, we get them back treating again. So keep in mind what they don’t cover though is a true maintenance. Supportive is different from maintenance. Supportive is in the absence of care, it significantly drops off.
Demonstrate that objectively and subjectively. If we’re just saying it stays the same and we don’t want it to get worse, that’s a difference. That’s where this comes in. The member’s symptoms are neither regressing or improving, is considered not medically necessary. If no clinical benefits can be appreciated after four weeks of acupuncture, then why?
Now, notice what it says here. They’re initially giving everyone probably four weeks. Now, four weeks for you could be one time a week. For another person, it could be two times a week. So, keep in mind, it’s not just number of visits, but over a time period. There are some service providers who might do one visit a week.
What I want you thinking of is, if I give care, Can I show improvement? No matter how many number of visits they’ll have, they’ll allow it. I have an office, and this is not a joke, they’ve treated someone probably the last, and I’m not going to over exaggerate it, for sure the last two years, I can say for sure, and they’ve treated this person 40 plus times every single year.
Now, grant you, they have a very significant chronic condition, arthritic changes, and so forth, but they don’t treat 40 continuously. They’ll treat usually 10 or 15 per an episode. They may not see them for weeks, maybe a month, and then treat another 10 or 15. And that same thing has gone on. What they haven’t done is just treat them every other week.
Now, some people might say, maybe that’s better. Well, unfortunately, that’s not how insurance works. So we want to make sure that we can demonstrate always meaningful improvement in symptoms and objective changes. And here’s a good example of a plan like this. This is the Costco plan under it. And I’ll just have you go to the first part here.
It says changes in coverage for chiropractic services. You’re thinking, what? Bear with me and let’s read on. Currently, chiropractic services are covered as an alternative care benefit. You pay a co pay for each covered chiropractic visit, and you’re limited to a combined total of 20 alternative care notice.
Acupuncture, chiropractic, homeopath, and naturopath. Costco is very generous. So what is that telling us? Do we get 20 visits per year? for acupuncture combined with others. But notice what began this year, January 21st, they’re allowing a little bit more for chiropractic, but it’s all based on medical necessity.
They’ll allow up to 90 visits per year. So what I want to highlight is visits, if they give you 90, 20, you still have to demonstrate the patient can get better as a result of the care. That doesn’t mean we’re curing, but maybe we’re getting to a point where they remain functional. And when that dysfunction drops, We continue treating.
Be careful. I think we’re the ones that have to explain to a patient. 25 visits doesn’t mean automatic visits. 25 visits still comes back to medical necessity. So we’ve got to give our patients a financial agreement. I hope all of you are doing something like this. It’s part of the no surprise, regardless of what a patient thinks is covered.
We want to put this out there. Many insurance policies do cover acupuncture care, but this office makes no representation that yours does. Insurance policies may vary greatly in terms of deductible and percentage of coverage for acupuncture care. In other words, we’re going to do the best job we can to get your plan to cover.
We’re not promising anything. What we’re promising is good care and that ultimately you will be personally responsible for the payment of your deductible as well as any unpaid balances. We go further to say if you have insurance, we’ll bill as a courtesy. Of course we will, but payment for your deductibles if it has not been met as your responsibility.
Your copay is due as services are rendered. What we want to do is give patients good quality care. And here’s something to keep in mind. Your practice as a cash practitioner is important, but it’s even the same when it comes to insurance. Insurance pays part of it. It’s just easier for someone to come in when they have insurance that pays part of it.
I want to access that, but I don’t want to give a false sense of security. Think of it this way. When someone really needs care, they pay for it. There’s a value. We want to continue to have that value, whether there’s insurance or not, whether it’s unlimited visits, that the patient understands it. Keep in mind.
Acupuncture care works really, really well. That’s the medical necessity. But does your documentation present that? This is one of the common problems I see when I have offices I work with in dealing with when they get denials or non payments. How do we fix that? Well, demonstrate the patient made, the treatment made the patient better.
I would implore all of you, acupuncture works really well, but if you look objectively in your notes, Can you see that in an evidenced way? I’m going to recommend that you always use an outcome assessment on every single patient. Even if it’s cash, by the way. Get an outcome assessment. It demonstrates objectively how the patient is changing.
The two that I like the best are the general pain index. The other is the pain interference, the short form. The latter is the one the VA is emphasizing. If you’ve attended a seminar with me, you’ve received them. If you’re a network member, But start using things that show acupuncture works. It’s your way of putting a person on a scale and show they’ve lost weight.
Acupuncture is a phenomenal profession, but you have to make sure how do I navigate to continue to increase my patient base, which means also increasing your volume of patients by volume of income. Because ultimately, remember, you are a business provider and we’ve got to make business decisions. So I always want to be there to help you navigate that as the American Acupuncture Council does.
So until next time, my friends, I wish you the very, very best.
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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.
My friends, it’s Sam Collins, the coding and billing expert for acupuncture for you, the profession, and of course the American Acupuncture Council. And thank you for spending some time with me. This is an important time of year because here’s a riddle for you. When do the 2025 diagnosis begin? Now, the quick answer to that riddle might be Sam, you said 2025, it must be 2025.
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Actually, it’s not. The 2025 diagnosis codes, as they do every year, actually update the October 1st before. The answer to the riddle is, the 2025 diagnosis began October 1st. So make sure that if you’re using one of these codes that I’m going to go through to update your list, to make sure you’re using the most current code for your patient, because if you use an old code, It’s going to be denied.
Now you can see here, or in fact, let’s go to the slides. Let’s go to the slides. Let’s look at it. So the update you’ll see here is the 2025 update is October 1st. You can see there’s 74, 000 diagnosis. Now let’s be realistic. Is an acupuncturist going to ever use anything like 74, 000 diagnosis coords?
Of course not. However, a lot can be covered because acupuncture, of course, for pain and pain management has a lot of ways of being coded, but you’ll know one of the most common things you’re billed for, or paid for, I should say. In fact, that’s the code that made the biggest change for you. But let’s keep in mind how these work.
The date of service determines the code. So let’s say, by example, you’re billing a patient that you saw in September of this year, but you’re sending the bill in December. or January for that matter. It’s being a little late, but you’re still sending. It doesn’t matter when you send the bill. The date of billing does not affect the code.
It’s the date of service. So if the date of service was prior to October 1st, please use the old code. If the date of service is after, Use the new code. Pretty straightforward and simple. However, let’s talk about what if change. The changes are occurring for lumbar and lumbosacral discs. Now, as an acupuncturist, you might say Sam, I’m not sure that’s very important to me.
Certainly could be as a lot of acupuncturists now are working as the referral person for back pain and pain management for medical doctors. You’re often going to get patients that will have these conditions and often they’re not going to put a code for you. It’s just going to say, Dysdegeneration.
Right now the code is M5136, so pretty straightforward, M5136, that’s fine, but here’s what’s changing. The changes now, they’re going to be a little bit more granular or more specific, where it allows you to describe what’s going on with the person. You’ll notice this first code, M51360, is dysdegeneration to the lumbar region.
with back pain or discogenic back pain, meaning back pain. So that’s pretty straightforward that it is back pain, of course. However, could there be more? There is more. M51. 361, other intervertebral disc degeneration in the lumbar region with lower extremity pain only. Now notice there now is a code that is back pain only or one that’s lower extremity pain.
So many times a person will have disc degeneration and go, man, my leg is killing me. And it’s actually from the disc. So now there’s a code to differentiate that, but there’s also one when it’s combined. So if you have a patient with combined back pain and leg pain, there’s now a code M51362. Clearly a person with back pain and leg pain, a little more severe, of course, meaning more care long term.
So this really, I think, sets up to demonstrate the length of care someone is likely going to need based on a diagnosis. Now, we have back pain. Leg pain and a combination of both, but there’s always this one too, and I’m sure you’ve seen this. There are many people that maybe they went in for some upper back issues, but they did an MRI or x rays to other areas and they found, oh, there’s disc degeneration in the lumbar spine, but it’s asymptomatic at the time.
If there’s disc degeneration that’s asymptomatic, there is now a code. Disc degeneration without mention of pain, In the back or lower extremity pain. I like that. That kind of lends to, that doesn’t mean the person is fine, but it does mean that they’re obviously having disc degeneration and we know they’re going to be closer to having a problem.
So what this does is just add a little more specificity. If you were seeing these codes, please make sure to add these new digits to get that specificity for it. Because if you send it in 5136, It’s going to be rejected unless of course it was before October 1st. They’ve done the same thing for lumbosacral discs.
There’s M5137 lumbosacral discs, meaning L5S1. But you’ll see it’s the same protocol with back pain, with lower extremity pain, or a combination of both. So just making sure no longer now is it just one simple code. But there’s going to be three codes demonstrating when it’s hurting, Or one if there’s asymptomatic.
Now you might think Sam, I don’t know if that’s significant to me. I’m an acupuncturist, but if you think of it, how often do you treat people with chronic back pain that often could be disc related, you may not be making that as the primary code, but if it’s on the claim, we better make sure we have the right code to it.
Now, one thing to keep in mind though, let’s say you’re coding someone with back pain. Just plain back pain. You cannot use a back pain code with the disc code. So never combine like an m51 series like lumbar disc or lumbosacral disc with a pain code. In my opinion, obviously you’re gonna use the disc code.
It’s more severe. I mean think if you said someone has back pain compared to saying discogenic back pain or disc causing leg pain, I think you’ll see the severity levels a little bit higher. Probably longer term care. Bottom line, I want to make clear those. Don’t combine them. If you say, Sam, I don’t want to use a lumbosacral disc code, I would say why not, if it’s already been coded for you.
But if so, make sure not to combine it with the back pain codes. And let’s keep in mind, back pain codes updated. What is that? Four years ago now, however, I wanna make sure it’s clear. The back pain codes are M 54 50 for unspecified low back pain. We have M 54 51 for vertebral genic, low back pain, and then we have M 54 59 for other low back pain.
You might be thinking Sam, that’s not new. Why are you updating it? ’cause this is a problem. I see. Obviously many acupuncturists now are beginning to access particularly Medicare. Part C plans. These are your Medicare Advantage or private pay insurance plans that many will have direct access for acupuncture, not needing an MD.
When you have a plan like that, do not use M5450. Please make sure you’re using M5451. Or, M5459. If you use M5450 for the Medicare plans, you’re going to reject it. So keep in mind M5451 or 59. My opinion, M5459, best choice. Other means something that you can name or the reason for. It could be pregnancy related for that matter.
Bottom line is, no pain codes with DISC. If you’re coding DISC, here’s what I’ll tell you. The association is it’s already there. Now you can see there is a code that says no pain, but In other words, don’t put pain with it, but one or the other. Now, there’s some other codes that are musculoskeletal related.
You might look and go Sam, I don’t know if I’d ever use this. And I’m going to say these aren’t probably common, but I want to make you aware. Because as you can tell with diagnosis, they’re commonly looking to update and make things more granular, more explained, if you will. Currently we have a code that just says, Sinovitis, tenosinovitis.
Unspecified. And that’s basically your tendonitis codes. Here’s what we have now. Codes that are specific for these conditions that are going to each area. Shoulder, arm, forearm, hand. So everything upper extremity. In addition, lower extremity. So you’ll see here thigh, lower leg, ankle and foot, and so on.
The idea is that coding is always there to try to give us our best way of describing what’s going on. At the same token, don’t be afraid to be simple when it comes to acupuncture. Often a pain code is going to be your best bet. However, when I can have something more granular, I like it. Think of disc degeneration with pain compared to just back pain.
I think we see two different things there. But also know what the carrier requires. So by example, if you were billing Aetna, even though they may have a disc issue, You’re going to code it as pain, because that’s what they accept. Cigna Insurance, Anthem. Others will accept the DistriGeneration, so know which plans you’re dealing with.
As always, the American Acupuncture Council is here for your help. I run our network. The network services, we do seminars, and we do one on one help. That’s really what we do. If you want to make an expert part of your team, take a look at our site. Take a look at what we offer. We give you two CE seminars a year, plus unlimited access to get with me.
So we can go over everything in your practice. What are your fees? Are you building the coach properly? How do you document? How do we make sure we’re getting paid? We always want to make sure you have success because your success is ours. Until next time, my friends.
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