Tag Archives: Sam Collins

Does Your Documentation Match Your Services?

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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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Take care everyone. . .

Are You Setting Yourself Up for an Audit?

Obviously, no one wants to be audited for anything. Let’s face it. No one wants to go to the I R S and be audited, but what I will say is, often the people who try to bring this up often do it in a way that they’re ultimately just trying to scare you..

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Hi there everyone. This is Sam Collins, the coding and billing expert for acupuncture for you and of course with the American Acupuncture Council. We’re gonna talk today a little bit about something. I know many of you hate to hear the word. In fact, it’s considered the a word audit. I’m in trouble.

What’s happening. Obviously, no one wants to be audited for anything. Let’s face it. No one wants to go to the I R S and be audited, but what I will say is, often the people who try to bring this up often do it in a way that they’re ultimately just trying to scare you and trying to elicit a response of fear so that you do something that they have like they’re the magic.

Clearly. I. Audits can be a problem, but I wanna talk about it from a standpoint. Is it really as much as people say, and are there some things that may make you more vulnerable, less vulnerable? Let’s get into that part of it. Obviously what occurs is many times an insurance company is simply looking at what you have billed and whether or not it was documented.

This doesn’t have to be insurance though. This is where people often have some misgivings. Quite frankly. If you’re doing a cash patient, there’s a complaint. They’re gonna look at your notes to see did what you say you did happen in the notes. And really, that’s all it comes down to. I’ve not really seen a lot of audits for their coming back for medical necessity, and I’ll never say that doesn’t happen.

But most often for Accu is, Hey, you build out something. Did you do it? And you have to think of what causes this? Why are they looking? I will tell you, in many instances, UnitedHealthcare recently seems to be the one that’s doing this the most, and I’m finding that often, to me, it appears they’re doing it because unfortunately, acupuncturists generically have some pretty poor documentation habits, and as a consequence, it’s low hanging fruit.

If they look at your notes. It’s not documented well, and I wanna make sure that we prevent that ’cause what triggers them to look at it, why? And often there’s these little triggers that happen. But let’s talk about it from this standpoint. Who protects you? You’re protecting yourself to start, but then you may have someone else behind you.

Like obviously I’m an expert and if you work with me in the network, I would wanna audit your notes myself to make sure they’re okay before even someone looked. But let’s talk about malpractice coverage. Obviously you all have malpractice coverage and the main reason you have it is just for that malpractice.

Frankly, there’s not a lot of malpractice, and I’m not saying it never happens, but it’s actually pretty rare. That’s why for the most part, your coverage is so low. But one of the things I want you to think of is do you have coverage for other than just malpractice by example, the most common thing I see an acupuncturist looked at for are gonna be either from the board.

Or it could be from an agency including an insurance on the documentation of your services that we call an audit. If you’re with American Acupuncture counsel for insurance, do you know it’s included up to $30,000 of defense, meaning they bring in attorneys of people to protect. You realize, invariably when I see an office audited and an insurance company has said that it’s not proper, most often it is.

Once we can work with it, or even if it isn’t, I wanna work with you to make sure, is it, and that’s how I’m gonna focus today, a little bit on that part of it, how to make sure that if you are audited, what do you need to do, but what things can trigger it. So let’s talk about the first thing that triggers someone to maybe want to look.

And frankly, it comes up when you bill something that’s unusual or out of the ordinary. In other words, if you’re floating in the middle of the stream, you’re okay. But if you get to the outsides, things can get a little bit trickier. Probably one of the big areas is your exam codes or evaluation and management codes.

What code are you choosing? Acupuncturists often will choose high level codes, which can be appropriate in many instances, but we wanna be careful if your style. Is to spend an hour with every new patient, meaning you’re billing a 9 9 2 0 5 every time. That’s a little unusual, and that’s not to say you wouldn’t have some, but to spend an hour with every patient seems a little bit odd.

Clearly, as an acupuncturist might you have a patient you spend more time with on average, simply because maybe they’ve been to two or three other providers, they have a long-term chronic condition. That history of evaluation may take longer, so certainly could be appropriate, but not everyone think of it simply.

If someone has chronic low back pain, surgical candidates been to a chio, a pt, medical doctrine, all of those things, I would bet that exam takes longer ’cause just the history of information they need to give you. Comparatively though, if someone has a hangnail, I wouldn’t expect that same type of exam.

So be conscientious. What triggers an audit or someone requesting records is when something is unusual. If you are billing a high level e and m code on a regular basis, you have a greater tendency for someone to look. Now, if you are doing that exam and can justified, I’m all in, but realize you become vulnerable.

So if you’re billing with that pattern, your documentation may be better in order. Because chances of someone looking at it means they wanna see and does it fit by example? Have you ever audited your own records? Like when you bill a 9 9 2 0 5, have you ever looked at the notes and said, do these notes meet that level of coding?

Did I have the medical decision making? Which is probably not, we don’t see things that severe Or do I have the time that justifies it? And often I found it doesn’t. So I want you to start to look and go, let’s make sure if I’m coding it, lemme make sure I know why. I’m picking that e and m code, and I would say that even applies with a 9 9 2 0 4 2 0 5.

The other place that runs into a problem is just the frequency of an exam by example. A lot of people come to me and say, Hey, Sam, how often should you bill for re-exams? And this is across the board. Really, even if you’re not an acupuncturist, a chiropractor, a medical doctor, is expected that re-exams are about every 30 days for recurring care of a patient’s condition.

If it’s sooner than 30 days, that’d be a little bit like why now? Could there be reasons for it being sooner than 30 days? Of course. What if you’re seeing someone for headaches and neck pain and then they come in on the next visit and say, Hey, last night I tried to list something. I twisted my low back, I felt a pop, and they have low back pain.

Sure an exam is appropriate ’cause it’s a new condition or new complaint. But if it’s to deal with the same area, chances are not until every 30 days. So be conscientious. What insurance companies do and what everyone does is just look at an algorithm. How often is something being billed and where do you fit with your peers?

If you fit outside the norm, someone’s gonna think we’re gonna take a look by example. Blue Cross sent out letters. Blue Cross Blue Shield sent out letters to many providers last year. On that factor about the frequency of the codes for E and s, but also the frequency of acupuncture. In the letter, it doesn’t say that you’re doing anything wrong, but it says your numbers are above the norm.

We want you to look to make sure it’s justified. To me, that’s a warning that an audit is impending. Now, I don’t care about an audit so long as we’ve documented and have the reasons, but I prefer not have to go through it. So high level e and m codes are just a very great frequency, is definitely one trigger.

So keep that in mind. If you have exams done every 30 days for ongoing care, you’re billing oh threes with an occasional oh 4 0 5, I think you’re gonna have no issue. The other area is just the sheer number of services you provide. Now for acupuncture, as I’m sure many of you are aware, you can bill up to three sets that are payable, and I haven’t found too much of an issue billing up to that number, however, Keep in mind if you bill everyone three sets, no matter what, that may be your style or technique, but be conscientious.

That shouldn’t. Some people have less or more. Now, I’ll never take away if that’s the style, but keep in mind when that number is higher, it’s gonna afford someone to look. Now, I do not care if you build three sets, two sets, whatever. Just make sure it’s documented. The problem I find is that many acupuncturists are never taught properly.

The documentation. And remember, documentation of Accu Acupuncture requires two things. You have to document the time. This is the time with the patient, and realize that time is soon as you walk in the room and say, Hey, Mrs. Jones, how are you feeling? That starts the time. It includes also tongue and pulse and evaluation, day to day-to-day, but also sterilizing your hands, preparing the points, choosing marking, inserting needles, all of those things.

So document that along with what points you have done. If you have that, we’re okay. Unfortunately, I’ve seen a lot of offices that don’t document that they may document one way off the other. So if you’re going to document acupuncture, remember it has two things, time and the points of each set, and they must be separate.

The time a person resting on needles without any active part to acupuncture does not count, but the active part of it and realize that takes a lot more time than people realize. It’s not just the point of inserting the needles. But all the things that lead up to, into, and the removal. So make sure that’s documented.

But again, if it’s more than three, so be it. There are, most plans won’t cover more than three, so if you do more, that’s fine. It doesn’t really matter. Just make sure what’s there is documented. The other trigger, of course, is just the sheer number of visits that the patient has. If you have a patient with an uncomplicated condition that you treat for a very long time.

The chances are someone’s gonna eventually look and go, is this care working? Why is this person continuing? Are they getting better or not? And again, it doesn’t mean it’s wrong, but they’re gonna start to question the efficacy. I would say start thinking of when you say someone has a stagnation or a chief stagnation, think of that as a functional deficit.

As they get better, the she improves, which means the function improves. And if we’re demonstrating that, I think medical necessity becomes a lot easier, but length of care can be a factor. But what about length of care? Depending on the condition, simple, low back pain, I would expect not to take too long.

But what about some of that’s had chronic recurring low back pain? That’s a little different. Maybe they have more complicated conditions. Maybe they have a disc injury. So there could be factors that are involved within that. So keep in mind, all I wanna make sure is that if anyone ever looks at your notes, they’re justified.

Let’s face it, people think all the time that’s only gonna happen with insurance. No, it doesn’t. If a patient makes a complaint to the board or has an issue, the board is always gonna want your records, and the board has certain standards that must be met regardless of insurance billing. So please be careful.

Don’t think because I’m billing cash or getting paid by cash, my documentation can be sloppy. No. You still have to have the same detail to indicate what services were provided. You can’t just do, I did acupuncture and it was $75. So give me a little bit more. The other factor is just number of services, and I’m talking generally, I talked a little bit about acupuncture, but what about additional services?

If you’re doing twin on gu sha cupping, those are all fine, but what if you have a person, you’re doing eight things on a visit? Does that not seem maybe just a little excessive? I’m not saying it absolutely is, but that would be unusual. Unusual things get looked at. Now, unusual on an occasional basis.

Everyone gets that unusual on a consistent basis means what’s going on in your office. That’s different. What I prefer to do is flow in the middle and when you get outside of it, if someone looks no big deal. One of the things I do with our network members when you join is I audit you. One of the requirements is I wanna see a sample of two or three claims from you, whether cash or otherwise to see are the things you billed for.

In the notes, because here’s what I found. I had an office once that had an audit, and the notes they requested, quite frankly weren’t very good. The insurance company was coming down on them, but because they’re with American Acupuncture Council Plus with me, we went back and said, yes, actually, we did an audit of this office six months prior and we found certain deficiencies and we have them correct them.

To include all the things they needed. Do you know they didn’t have to pay anything back in that audit because they showed there was compliance that, yeah, that older claim had that. But take a look at a newer claim where you can see that it was fully documented. Realize sometimes you’re just not doing things because you didn’t understand what was necessary.

If you show that correction can probably make all the difference in the world, and I see that happen way too often for you to not feel panicked oh my God, I’m gonna get in a lot of trouble. Most often, they’re just looking for you to be compliant. We see it with the VA and other plans, they just wanna make sure if they’re paying for something, that the person got it.

So if you’re doing a lot of services, great, document it, but also give me a reason why it can’t just be that’s what I do with everyone. No, it might be, that’s what I do with everyone with this particular condition. But not one that has a hangnail and a disc injury. You get my differences there. So thinking this way, don’t overly panic about an audit, but realize anytime anyone looks at your notes, they’re being audited, they’re looking, let’s make sure they’re in place.

So here’s some things that I wanna make sure that you’re doing. So let’s go to the slides, let’s talk about them so you can get a little visual of it as far as what’s happening. And you’re gonna look at what things are gonna trigger. So let’s get to the slides. I’m hoping my slide person is there to bring those up.

I’m not seeing them yet, but we’ll start there. I’ll wait for them to come in. But one of the triggers, as I mentioned, is gonna be high level evaluation and management codes. So keep in mind if you’re billing oh fours or oh fives, you have a greater chance of someone looking at you, which I do not care.

Just make sure they’re documented. So if you’re billing a 9 9 2 0 4. Or 2 0 5. What are the main things you’re gonna need to have? Remember exam codes are based on medical decision making or the time now medical decision making. I don’t think an acupuncturist is probably gonna see a condition that meets the medical decision making for a 9 9 2 0 5.

I’m not gonna say never, but very unlikely. ’cause you don’t see life or death things. However, what do you meet Time there could be a patient, let’s face it. That’s been to all these doctors that I mentioned. It could literally take a 45 minute interview plus an exam that takes an hour, so that certainly makes sense.

The same with the 2 0 4. Remember, that’s 45 to 59 minutes. Now, as an experienced acupuncturist, often once you’ve been around a while, do you really require that you spend an hour? I think in many instances, not don’t be overly concerned of, I don’t meet the medical decision making, but the time is there, which means document time.

Tell me how much time did you spend on this exam? If you’ve done that, you’re covered. Now be careful if you have an exam that you said you spent an hour and I see a half a page of information, I would go, how did that take an hour? That would seem unusual, but keep in mind, what if that person was hard of hearing?

There could be other factors, part of it. So high level e and m codes, and I’m hoping can someone go to the slides for me? The next factor is just simply evaluation and management frequency. Are you billing exams too frequently? I’ve had acupuncturists that mistakenly would bill an exam every visit. That is not appropriate an exam.

Every visit is not, it’s about every 30 days. So a lot of people think I can bill one ’cause I have to evaluate. Of course you do have to evaluate a patient each time, but the evaluation you do on a day-to-day visit is part of the acupuncture. . When you bill an e and m code or an exam, that’s when you do the big full thing.

So think of every 30 days. If it’s any sooner. Always do this check if I’m doing it than sooner than 30 days. Do I have the reasons behind it? In other words, do I have new condition, significant complaint, or change without that rethink and go why am I doing that? The next factor is greater than three sets of acupuncture.

I am all in and I have some acupuncturists that are mad and say people shouldn’t even do more than one set. I will never get into that argument. You do what you feel is necessary. Just bear in mind when you do more sets, someone’s gonna look and go, why is this always doing more sets? Nothing wrong with that.

But if you’re doing three sets of acupuncture, let’s remember what is the minimum you have to have documented? You must have 53 minutes of face-to-face time and no single set because there’s three is less than eight minutes. . So make sure the time matches and you have documentation of time and points for each set, and that’s the face-to-face time doing the acupuncture.

The other thing is just plain acupuncture documentation. Please take a moment to look at your notes and see that you have those two elements. That’s not really that hard. I wish the schools did a better job of teaching it, but this should just basically tell you from the start, always tell me time and the points.

If you have that, you’re fine. Where I think we run into a problem is people forget that and all you have to do is document it invariably, and I’ve been around acupuncture for 25 years as a patient, partly, but also as an expert on the coding and billing. And I invariably find acupuncturists generally will always tell us they see patients longer than the average provider.

I agree. I agree. I see that too. However, what do you need to do? Tell me the time. Tell me the points of each one. If you have those in place, we’re gonna be okay. And then just about therapies. If you are doing therapies in addition to acupuncture, I’m all in. But let’s be careful of not having eight or nine units of therapies.

Try to stick with four or less. If you’re doing three units of acupuncture, I would stick with maybe no more than one or two things that are therapies outside of it. Not to say never ever. But again, on a regular basis, we are not trying to do everything plus the kitchen sink. Keep it in mind. But if you’re doing more than that, what do you have to have documented the services?

If you’ve done more than four units or services, good documented. But if I did four units a time service, remember now my time has to equal 53 minutes. In addition to that, if I’m doing even more than that, I might have to as much as an hour and 15. Keep in mind, I had an offices a few weeks ago that they’re being questioned.

That they were billing for more times than their office was open. They were billing out, 20 hours of services and you’re thinking, how can you bill 20 hours of service in one day? For this office actually was quite simple. There was more than one acupuncturist working in the office. And part of it, they weren’t showing which acupuncturists were doing the care.

So they always thought it was just one when there actually were three acupuncturists. That makes sense, but it was looked at. Now, once they figured that out, they were fine. But remember, you can’t do more than one hour of acupuncture in one hour. So you can do four units, whether you’re gonna do four units on one patient or divided up among two or three or four depending.

So keep that in mind. And then just remember, always look at long-term care. If you’re doing long-term care, I get it. . But if it’s an uncomplicated condition, why? Realize there’s gonna be a point of, is the care really helpful? Now, I’m a believer in palliative care. I think it’s important, but let’s remember that isn’t always what an insurance will cover.

And this is where with insurance, it’s a bit different. If a person’s paying cash, you do palliative care all you want. Just make sure they’re aware of what it’s doing. So keep in mind here will be the point document. If you’re doing an , make sure it meets the amount of time or medical decision making, either one.

I think it’s probably more, mostly time. If you’re doing acupuncture, document the face-to-face time and the points of each set. Not a big deal. Not very hard. Once you learn that your life will be easy. In fact, I would say for acupuncturist, your documentation is quite easy, but it’s not something that you’re doing if you’ve never learned it in that way.

So time and points, and just make sure the care plan matches complexity. Simple pain or simple problems shouldn’t take as long, but things can take longer. But there’d be reasons behind it. And that’s not always documented or reflected in the diagnosis because often you’re limited to just the symptom.

But realize in the notes, don’t be afraid to include all of the complicating factors. Even the VA talks about this. What if you have a patient that’s diabetic, they’re very overweight, they’re very deconditioned. I don’t care what you’re treating ’em for. With those three things on board, it’s gonna take longer.

Even though you’re not treating the obesity, not treating the diabetes, it’s still gonna complicate it. Not to think that maybe some of those things might get better if they’re in less pain. Maybe they can be more active, lose a little weight, and all those things. But keep in mind, there’s reasoning. All I want from you is simply when you’ve billed it, make sure it’s there.

I’m your advocate. Make sure that if someone looks at your notes, they can see what you’ve done. It’s documented properly. No issue at all. I don’t care if you’re audited, just document the services. No one can ever come back and say you should have only done two sets. Who says you should do what you do?

Based upon your experience and expertise as a provider, you might wanna say, what do I ever get a chance to have that looked at? Our network service does that. I would say definitely take a look. That’s what we do. We offer you a way of looking at that beforehand, and it’s just part of the overall service.

I have a vested interest in you. . If you’re not successful, you wouldn’t need continuing education. Therefore, why would I exist? Your practice is not surviving. I’m not surviving. So we’re gonna be your advocate. The American Acupuncture Council is always gonna be your resource. Give us a call, make sure if you need help, we’re here to do that.

Until I see you next time, document. But take care of your patients and do well, my friends.

Prepay Plans – Are They A Barrier to Care?

What about prepay plans? Let’s go to the slides, let’s talk about that. What are or. Prepay acupuncture plans. What is possible for us? What can we do with it? How do we make sure it’s legal?

Click here to download the transcript.

Hey, greetings everyone. This is Sam Collins, your coding and billing expert for acupuncture and the American Acupuncture Council, the network, as well as the insurer. And as always, we’re here to try to help you fortify your practice, make things better. It’s a great time to be an acupuncturist. It really is.

There’s never been a better time. However, we have to figure out how do we make all these things work? How do we meet it up? How do we start to decide that we run the business end? This is the difficulty, I think, for many acupuncturists because you get through school. You do a good job to become the best acupuncturist possible, help people.

But then you have the reality of uhoh. I’ve gotta run the business end. That’s where my specialty comes in cuz we deal with the coding, the billing, but also all ends of it. And I wanna talk a little bit today about running parts of your practice as a cash practice, not just insurance. And how do we deal with that?

What about prepay plans? Let’s go to the slides, let’s talk about that. What are or. Prepay acupuncture plans. What is possible for us? What can we do with it? How do we make sure it’s legal? I think you’ve seen things like this. Here’s what I always think of. We have to provide a way that allows people access to our care.

And I think this is often where we run into problems, is not always understanding why aren’t people coming to us? So let’s look at it. Why do people not get acupuncture? Let’s think of that. Think of that and solve and think even your friends, what do they even know that you do? Some people will say, I hate needles.

Some could be, ah, it’s not gonna work for me. Oh, they’re not real doctors. But let’s base on what’s really changed. The Cleveland Clinic, one of the most renowned places for healthcare in the US recently published that says this, what type of pain does it? Acupuncture treatment. It says, many people use acupuncture to relieve pain throughout their body.

Including for migraines now, notice pain throughout the body, including migraines, back pain, arthritis. Studies have also shown that acupuncture may be his successful treatment option for a variety of conditions, including immune system issues, infertility, and the effects of menopause and so much more.

You are now able to access people in ways that I think 20 years ago, acupuncturists probably could never. Have thought of because the people now understand it. You gotta wonder, do people really know what you do? And this is something I’d like you to ask yourself and your family. What do I do?

Because I want you to think of what does the average person think? Now notice I said ask your family. Your family who’s, who loves you. I bet many of them don’t really understand what you do. And I’m not blaming anybody, but saying we have to do a better job of making sure people understand the why of acupunctures, the things you can do.

So think of it if someone went by your office. Would they know what you even treat? If it says acupuncture, you’re assuming they know. Notice these two offices I use as an example that talk about what they treat. Fatigue, stress, tension, anxiety, depression, mood swings, migraines, tension, headaches, digestive disorders, indige.

Congestion. Allergies, asthma, cough, women’s issues, neck, back and knee pain, arthritis, autoimmune, chronic, even va. What about personal injury? What about for that matter, Medicare. Medicare Advantage. Look at this other one. Neck and shoulder pain. What my point is, Why are people choosing acupuncture?

Partly because they’re not sure it can help cause they’re not aware that it could help ’em with menopause and frankly, whether an insurance covers it and some will. If you can help a person having issues with hot flashes and other issues. Is there a value enough to pay for that? I believe so.

But realize the barrier to care for most people, as we’re well aware in the us. Cuz my goodness, we have a diagnosis code. This is an actual ICD 10 code. It’s a P, it’s a code that indicates patients noncompliance with other medical treatment and regimen due to financial hardship. How many of us know someone that needs to go to the doctor?

We, we know they do, but they don’t. Why can’t afford it? Don’t have insurance. So that puts a dilemma here that realize a lot of times people aren’t choosing care because it’s just a factor of affordability. That’s what a capitalistic society does. I’m not blaming it, I’m just saying that’s a reality. So you think what about if they have insurance?

Insurance can be good. There are some plans that pay very well. There’s some plans that are horrible, meaning they pay, but very little. But keep in mind, there’s still gonna be sometimes no or limited benefits. Maybe the plan has a super high deductible. Okay. Or maybe there’s just no insurance out.

Patient doesn’t have anything. They don’t have a job that gives them insurance, if you will. While many people do, even when they do they have a coverage? Think of a Walmart worker. Do they have insurance coverage? Oh, sure they do. But do they have acupuncture benefits? Sure they don’t. Unfortunately. So here’s where I think we need to bridge is acupuncture, I think has always done a good job of not relying on insurance.

Not to say you don’t take some insurance. The good stuff. Sure. But you don’t rely on it because we know coverage patterns for what you do is not as well covered. That’s gotten a lot better, particularly in some states, but data suggests people are more willing to pay out of pocket for acupuncture than just about any of their service, cuz they’re used to it.

But there’s also a cause and effect I think. I want you to think of, if you’ve ever been to a medical doctor, have you ever left going, God, I feel so much better. And I’m not saying that is a putdown, that’s not how they treat. How many people come to you in a day that have a pretty severe amount of pain, a headache or something, and when they leave they’re like, oh my God, it’s 75% gone.

I’m not saying we’ve cured them in one visit, but you get my point. There’s value to that. So you gotta think someone’s coming in. How do I offer that in a way that they can afford it? What about discounts? And I think you’ve all talked about I’m gonna offer a cash discount. You can certainly have a, just a cash fee.

That’s whatever you want it to be. I. Unfortunately, if you’re billing insurance, it really can’t be much different. Remember, when you are billing insurance, your cash fee can’t be any lesser or any greater, excuse me, than would be five to 15% according to the Office of Inspector General. So that’s under federal rule.

So you give a small discount, but not much. So does that really help? What if you’re charging $150 and all of a sudden the patient goes do I get a cash discount? Yeah, sure. We make it 1 35. That still may not be affordable for them. So is there anything else we might do? That’s where pre-pay plans will come in.

Let me give one exception because obviously I’m gonna have providers from all over. Remember, California has an exception to cash discounts business and professions code 6 57. So in California, yes, you can offer a substantial cash discount as long as they’re not using insurance. But California’s unique in that no other state has that.

But here’s what I’m thinking of. You’re a business. You gotta think of it like a business, and this is where prepay comes in. Sears made a major mistake 20 years ago or so. Sears, someone at Sears should have looked and go, wow, this Amazon business is really booming and all they’ve done is copied us.

Amazon has nothing more than a copycat Sears. Sears was a catalog company and you ship things. They moved away from it when City Center started, but why didn’t someone at Sears go, Hey, let’s digitize this catalog, because at Sears done that. Do you think Sears would still be around? I think so. Because would you still buy from Sears if they could ship it right away?

Of course we would. In fact, what’s funny is all those big Sears stores, many of them are turning into Amazon warehouses, which I think is funny, but it just means they did not adapt. I want you to think of adaptation in your practice. What have you done that could be helpful to a patient to get more access to care?

I give a cash discount, eh, but I want you to think of, there’s a very popular group right now. That is probably the biggest growth of acupuncture for any place, and that’s the company, modern Acupuncture. How does modern acupuncture work? Excuse me. Modern acupuncture sells packages. Now I, how do they do this?

You wonder, is it legal? Excuse me. The discount is greater than the cash discount, and the reason why is a package. It is not one visit. So unlike doing a single visit, like what is billed to insurance, you’re billing multiple. So think of it, excuse me, the company Target. Have you been in there recently?

When you first walk in, do you notice. There’s a little 99 cents store there. Now, why did Target do that? People like the 99 cents store, so that doesn’t mean, pardon. That does not mean that you cannot still buy expensive things at Target, but it means they’ve also realized people like the 99 cents store, so they’ve adapted a little bit to satisfy that.

You can go in there and still buy a thousand dollars of other stuff. But by fi, but by a few 99 cents Store items. My apologies. I’ve been a little sick recently. Maybe I should get to an acupuncturist. Nonetheless. Think of modern acupuncture. Why are we allowing them to do that model without us maybe adapting it a little bit?

Why are they the only ones? And I will tell you pretty much in any state, You can offer what they do, which is a prepay. So your practice to continue to grow has gotta get access to people. And this is popular. How does modern acupuncture work? They don’t sell single visits. I’ll take that back. They do.

You can buy one visit, but it’s very expensive. If you buy multiple visits, it’s a lot cheaper. If you buy multiples, they can be as cheap as $20, but what it means is you buy them all at once. So here might be something you can offer someone. You have a cash patient who maybe your visit is 75 or a hundred dollars, and for them to come in three times a week, they’re like, Ooh, I don’t think I can afford that.

So you might say hey, you’re gonna need 12 visits to really clear this up. If you buy all 12 upfront, we’ll give you those visits for 500. In other words, you’re selling it as a package. Let’s say your visits are normally a hundred, but if they buy a package of 10, you sell them for 700, so they get a substantial amount off.

That’s exactly how this model works. I think it’s a way to think of another way to get a person access to care. Think of how people purchase cars. No one pretty much buys a new car for cash. And I’m not saying that never happens, but the majority of us put a down payment, make payments. Notice when they advertise the car, they don’t say the price.

No one’s gonna say it’s 75,000. They’re gonna tell you, oh, 2 99 a month. That’s affordable. So you wanna put this in chunks. I think this model is something every acupuncture should offer. It doesn’t mean it’s for every patient. But I think there are gonna be many that’ll say, you know what? I know I need the visits.

If I prepay it, I save a little money. It also makes the patient more beholden to care, cuz they’ve already bought the visit. So how do we make this legal to do this? A couple of things. It has to be a fee for service. If you’re gonna do a pre-pay plan, it cannot be for a thousand dollars come as much as you want.

It has to be for a thousand dollars. You get 20 visits. So there’s a set number because there must be a refund policy towards it. In other words, any unused funds or visits the patient get refunded. So if a patient says, Hey, I came in for, only five visits of the 10, they would give half of their money refunded.

No big deal. I would also be careful of putting a hard expiration. There should be an expiration, but meaning if there is an expiration, And they expires. You’d have to refund it. So I would just up it. In other words, you’re trying to put a person into a plan here would be my point. What if you could sell 10 of these a month for a thousand dollars or 500?

Would that be value? I think so. Realize it’s not for a patient using insurance, it’s for someone paying cash, but it’s another way of giving a discount beyond your regular 10 or 15%. That allows the patient to be better committed because you’re gonna tell them, look, you really are gonna need 10 visits to get rid of this problem.

But we know how most of us would work. If I feel better after two or three visits. I’m like I feel good enough. I don’t want to keep going, but if I buy the package, so here’s a couple of examples of states that have rules about it. Here’s one for Maryland, and it says from the board you can offer a prepaid plan, but it says, That the practitioner that chooses to offer prepayment plans must carefully explain it.

In other words, make it clear up front. This is what you’ve purchased. You’ve bought 10 visits. If you use the visits, great, we’re all good. You can buy more, but if you don’t use them, there’s a refund portion to it. And realize that swings both ways. What if halfway through the patient is unruly? Rude to staff for whatever reasons, and you don’t wanna continue their care, you can certainly discontinue it as well.

So I want you to see Maryland allows it. Here’s one even for New York. In New York, it says, may a licensed acupuncturist offer a discounted package of treatments and it says, so long as any insurer is not deceived, packages would not be contrary to New York law. Meaning it has nothing to do with insurance cuz it’s not a single visit.

Buy a package. Now, could a package be as little as three, four, or five? Sure. Modern acupuncture sells 24 cuz it’s always two per month. They’ll sell more than that, but that’s how they get you going. I like the idea of this. I think it’s another way of trying to reduce the barrier of money.

I. For a patient to come into your office, but we wanna do it in such a way that we can’t get in trouble later, that they’re saying you’re acting like an insurance. If you were to sell an unlimited visit for a set amount of money, that’s an insurance. It also means if there’s unlimited, what if the patient comes every time or every day or another patient only comes once and says, I want my money back.

You’re gonna say you bought six months. You only came once. That’s on you. It has to be a set fee. Realize some states get fairly strict and so I’m gonna implore you please verify with your state the rules. Now, if you’re in the in our network with me, certainly you can contact me, but again, that’s net members only.

American Acupuncture Council Insurance Information Network members can contact me and we can talk about your statement. I’ll give you a few examples. In Florida, they allow it, but the package can’t be more than $1,500. That’s the max. And if it’s above 500, you have to put the money in a trust account, meaning a separate bank account as they come and pull it out.

That way they know the patient’s money is there. Montana also requires an escrow account, and there’s no limit. I would say most states don’t require that, but just be sure. The key is make sure the patients get what they paid for, get the treatment, and if they don’t, they get refunded. I like this idea.

Think of it. Why do people mostly not come? Money is always a big factor. Let’s try to reduce that to make people allow to come in to pay in chunks or get a better value or discount. So here’s a few things for just basic compliance. Make sure you outline multiple appointments with a patient. I would really try to set a plan.

Don’t just make it, come in whenever, set a plan, have a recall system that you know you’re contacting the patient, Hey, you’re supposed to be in for the visit. Let’s make sure you’re coming in. Or if they haven’t been in a while, That you are allowed to discount services based on the reduced administrative’s expenses.

That’s the whole point of this. You’re discounting it cuz you’re not dealing with all the other stuff that goes along with it. And then notice here, the last thing, have a refund clause that states the patient may receive their unused prorated due to them if they wish to cancel. It’s not something they’re stuck, nor are you.

It would just be refunded. So when it comes to refunds, and these won’t happen too often, I have a lot of offices that do these. And I will generally have them tell me, Sam, I don’t get too many people ask for a refund. But what? When they do, you know what they do? They just refund it. Don’t get caught up in thinking how dare you?

If someone doesn’t like the service, they don’t like it, refund it. Move on to the patients that do. Bottom line is this, if your usual rate is a hundred dollars and when they buy the prepay, the rate drops to 50. So they get 10 visits for 500. If they wind up using only half the visits, they get half their money back, meaning $250.

It’s always prorated. You can’t say since you didn’t use all the visits, we’re gonna up the fee to our normal rate. It’s gonna be the discounted rate. The refund should be calculated on the paid rate, not your normal rate. Charging any more than the quoted amount is gonna get you in trouble and patients are would make a complaint.

So long as you’ve been fair, not an issue. In fact, you’ll find patients love these. If someone is unhappy or moving, so be it. I have one particular office and always think of her when I discuss this. She’s in California, San Francisco area. She sells packages, and I’m not kidding, that range from as little as 500.

Her most expensive package is 6,000. I kid you not, but she will admittedly tell you, Sam, I don’t sell that many $6,000 packages. She goes, I sell maybe two or three a month. I’m like, wow. Can you imagine someone buying a $6,000 package, two or three of those a month? It’s pretty good. To me, it’s just another way of having a person, getting access to, in a way that can make it affordable.

Remove the barrier of money, or at least something cheaper. Your practice is gonna thrive because you get patients. Patients come in because they need the care, they understand, and then put a value to it. Be careful. You don’t wanna overly cheapen it, but again, creating a greater way of access to it, just do it in a way that protects you.

I think this is a great offer. It’s not gonna be forever. And someone might say, oh, I don’t want it, but there’s enough of it out there. Why are modern acupuncture have so many places if it wasn’t working? Must be don’t be Blockbuster and Sears. Look and go. Why don’t I incorporate a little of that? I think that’s gonna be a safe.

An easy way for you to enhance your practice. It enhance access for your patients. Even if the doctor claims, Hey, I did extra services, just refund what they didn’t use. The American Acupuncture Council is always gonna be your place for help. I do a services I mentioned. That’s the network. So if you’re a network member with me, don’t forget, you can call me.

Zoom me. We work one-on-one. I become your in-house expert. If you’re not a member, think about joining. Go to our website, aac info network.com. Take a look at our services, but realize we’re always here to help. There’s always gonna be a place that we know. We’re gonna make sure that you’re okay because your success is ours.

Until next time, everyone, thanks so much

Acupuncture and Timed Therapies – Sam Collins

And one of the things that I get commonly, whether it’s a network member or someone coming to a seminar or someone reaching out from acupuncture today is how do I manage acupuncture with time services?

Click here to download the transcript.

Greetings, everyone. This is Samuel Collins. You’re coding and billing expert for acupuncture in the American Acupuncture Council with another episode. Let’s solve problems. Let’s make sure you have the right things documented. And one of the things that I get commonly, whether it’s a network member or someone coming to a seminar or someone reaching out from acupuncture today is how do I manage acupuncture with time services?

How does that mesh if I’m doing a manual therapy or a massage? How does that time incorporate with acupuncture? It’s actually not as complicated as you think. However, it’s something that I’ve learned because I teach in a lot of schools. Acupuncturists aren’t learning. So we wanna give you a better learning curve now to do this properly.

So let’s go to the slides. Acupuncture and timed therapies. How do we manage ’em? What’s the proper way to document these time therapies along with acupuncture? And what are the minimum times, because obviously you’re all familiar with the 15 minutes, so what does that really mean? So let’s talk about what are these 15 minute services and time services.

Obviously we know we have acupuncture. We have the four codes for acupuncture. The two first ones obviously for manual acupuncture. The ladder two are for electro acupuncture, and each of the codes indicate that you spend 15 minutes. Now remember that 15 minutes is 15 minutes with the patient. in the room.

So by example, when you go in the room to greet someone, realize your time starts. So one of the things I find acupuncturists often miss out on is the true understanding of the value of time. The time is not just the point of inserting the needles, but it’s all the things required to do such as, Hey, Mr.

Jones, how are you feeling today? So that 15 minutes is incorporated into the acupuncture codes and is a requirement for each set. Now what about therapy services? Now, I picked a few here that I say are maybe a little more common. I won’t say these are the only ones, but I picked electric, stem, ultrasound, auricular electricity to accu points, exercise, massage, manual therapy.

As I would say, these are generally the more common ones that are timed. They’re more than these, but, and you may be doing additional ones, but the big issue is how do I make sure the time for those. Meet and adjust with the time for acupuncture. If I’m doing them together, what are the minimums here? And this is the concern that we run into a lot of problems with that.

Someone will not document enough time. I generically will tell you, acupuncturists spend more time with their patients than most other providers, whether are chiro. PT or medical doctor for sure. I think acupuncture spend a lot of time because the way that you work, the type of services you provide. So let’s talk about how does acupuncture work.

Now, this is actually a page out of the C P T, and I’m just using that to make sure everyone can see. It’s not just us stating it, but in C P T, it indicates that there must be 15 minutes of time that’s face-to-face with the patient. Now, face-to-face doesn’t mean touching. Sometimes people think contact means, do I have to be contacting the patient?

No, it just means. You’re in the room. So literally once you go in, it counts. So I wanted to make sure you can see it from that standpoint, but let’s take a look at it as it’s written out. Each code indicates pretty much the same thing. It says acupuncture. Of course that means needling with one or more needles and then says without electric stent, because these are manual and it says 15 minutes of personal, one-on-one contact.

So that simply means we’re in the room with the patient having contact with them. For the acupuncture service, which includes the pre, the during, and even the after. So the first set says 15 plus needles. Notice the additional set or additional sets says the same thing. Each additional 15 minutes of personal one-on-one contact with reinsertion of needles are really an additional insertion of a needle.

So bottom line is 15 minutes plus insertion. Equals each set. Now that goes with whether it’s manual or electrical. The only difference of electro acupuncture codes, 9 78, 13 and 14 is that at some point the needles have electricity attached. So you’re doing some type of device where you’re con contacting the needles and having electricity throughout.

Bottom line. It’s just simply 15 minutes per set. Pretty straightforward, but sometimes people have a hard time understanding. What does the 15 minutes constitute? We’ll get into that because let’s look at what other codes are. 15 minutes. Now, this is a list of all of the common physical medicine codes.

If you’ve been to a seminar with me, if you’re part of our network, of course you have access to this. And all this is a simple list of therapies you’re gonna notice in the upper left side is gonna be the unattended therapy supervised. The constant attendance, the therapeutic procedures plus the acupuncture, even dry needling listed nonetheless.

Let’s talk about specifically what are the timed services? Timed services are the ones that indicate time. You’ll notice the first ones that say supervise like. Infrared heat or something, they don’t have time, so these don’t matter. Those you just do or don’t do. There’s no minimum or maximum.

However, where you see ’em say constant attendance, you’ll notice now each of these indicate 15 minutes with each. So much like acupuncture. That means you have to spend 15 minutes with the patient. Now that doesn’t mean necessarily that your hands on though it could be, but it means you’re with the patient as the therapy is being provided to monitor the efficacy of it, if you will.

Now, commonly it could be electric stem, handheld type, not a type where you put pads on where you hold it by hand. Here’s that code I mentioned, the electric stimulation of auricular, acupuncture, literally electrical impulses to the surface of the year. at acupuncture points but not needling.

Those all indicate 15 minutes. In addition. In 15 minutes are the common ones that you’re gonna do. And of course I think most acupuncturists, and I shouldn’t say most, but many do incorporate therapies as part of their practice and may do some body work with a patient, whether it’s twink, haw and so forth, certainly gonna be applied to it.

And those notice all indicate 15 minutes. So what this is focusing on is making sure do I have the time? and understand the timing of it. I just taught a class last week to students at Emperors College, a college acupuncture college in Southern California, and I was surprised to see how most of them were getting ready to graduate and really had not learned anything about time.

So it’s one of the reasons their instructor had me come in, because it’s one thing to learn to be a really good acupuncturist, but we do have to understand the business end of it. How do I document this? And I don’t care if you’re not billing insurance. , you still have to document the services you’ve provided.

So let’s talk about the acupuncture time. What does it mean? What does it mean to do time in general? Now, what you’re seeing here is actually taken directly from cms. As well. And when CMS means Medicare as well as the American Physical Therapy Association, the ama, and all the adaptation of this, and it talks about counting time, and I want you to notice when time is not just time touching the patient, but notice it says time of therapy includes.

Assessment and management time, medical record review, physician contact while the patient is present. And so what it means is when you’re in the room and you’re looking at the notes and you’re getting ready to start part of it, thinking, okay, last time I did this and I’m doing, you’re gonna count all that time.

So what I’d like you to do is start thinking of when you go into the room, Either you’re starting acupuncture, so the time starts then, or maybe you’re gonna be doing a therapy. It starts when you contact the person. So this means the things you do before the service, that’s part of it, if you will. In addition, of course, it includes the hands-on treatment time, obviously, but then it’s also post-service work.

Notice that includes things like assessment of treatment effectiveness, after you’ve done making sure the patient’s feeling okay, sitting upright, making sure they don’t have any needle sickness. All those things would be included. But notice it also says, Communication. So you know those few minutes you might spend with a patient at the end of the visit communicating some things about their therapy that would be included.

I wanna be careful. It’s not overstate post-service time, but it’s certainly part of it. Here’s why we have to make sure we’re accounting for it, because I know the codes save 15 minutes. But the codes have what we refer to as an eight minute rule. Now the state minute rule is put out through C m S and adopted by every insurance, and it talks about the time required for a time service is actually not 15 minutes.

The time is actually as little as eight for one unit. It means you’re doing more than half. So the bottom line is if you were to do acupuncture or a therapy for as little as eight minutes, it could be billable, assuming there’s only one unit or set. Now, here’s where things get slightly tricky, but not too hard to understand.

Notice it breaks it down one unit. Of services. Now, I’ll even say one set, cause I like to think of acupuncture and sets. Notice one unit is as little as eight minutes, but notice it goes all the way up to 22 minutes. So if you’re doing a set of acupuncture or a therapy anywhere from eight minutes up to 22 minutes, that is simply one unit.

A second unit or time factor doesn’t begin until you’re eight minutes into the next service, which means now it’s gone to 23 minutes. So notice 15 plus eight, always the eight minute part. So it goes in that pattern all the way through. Notice two units or sets would be as little as 23 minutes. Three would be 38, 2 meaning 15, 15, 30 plus eight, and so on.

It goes all the way through. Now, that’s not too hard to see. However, it becomes an issue when, what if I’m doing two services, obviously, like acupuncture, I might just do ’em, look and go, okay, I did that, but what about a time service? And this is where things get confusing. . Where does that time count?

And again, I wanna make an emphasis here for your acupuncture time because I think many of you forget what constitutes it. It’s not just picking points and inserting needles and removing, but it includes all these things in red. Include a review of history. When you walk in the room and say, Hey, Mr. Jones, how are you feeling?

That’s when the time starts. It includes day-to-day evaluation, pulse points. Tongue, maybe range of motion, whatever you do. Obviously, cleaning your hands, choosing and cleaning the points, inserting, manipulating the needles, removal and disposal. Wow, all of that’s included exactly as well as completing the chart notes.

So clearly there’s a lot of time. If it’s an activity that’s related to acupuncture, it certainly counts what doesn’t count, and I underlined this at the end, the time the needles are retained is excluded. So be careful. You know how you might have a person rest on needles for 10 or 15 minutes? I. Perfect.

I know when I go to the acupuncturist, generally when she inserts needles for about 10 or 15 minutes, usually says, Hey Sam, I’m gonna leave you here and let you cook for a little bit, if you will. And then she’ll let me lay there for 10, 15 minutes, relax, and then come back in. That time does not count.

Now what if you did stay in the room though? What if you stayed in the room and every few minutes you stimulated the needles or you’re looking for patient response whether to insert more? That will count and it would count if it as an additional set once you would insert more needles along with that time.

The key factor here though that’s complicated is that I can only use one time code at a time. I can’t do two time codes and I have to meet the minimums. And what I think probably makes it simple to think of whether you’re doing acupuncture by itself or acupuncture with a therapy time is cumulative. So it’s not a separate time for additional services.

It’s an included time. So even though you might be doing two different things, massage and acupuncture, The minimum time to build a unit of each means you must spend 23 minutes total with no one of them lesser than eight minutes. So one thing to keep in mind though is let’s document this. This is not hard.

You spend a lot of time. You know what I’d like you to start doing. Tell me what time you entered the room, what time you left. , if there’s a particular therapy, tell me what time you started, the efforts of that and what time it was completed. But do keep in mind time documentation is only two ways it can be done.

You can either tell me how many minutes you spent. That’s easy enough. I spent 15, 18, and so on. Or you can say I went from nine 30 to 9 45. Now where I would be careful, I find often when people state minutes, their minutes are off in an average, and you may be undervaluing it. . My preference would be to actually tell me start and stop times.

Now either is acceptable. Just be careful of shorting yourself. You ever have that where someone says, Hey, how long does it take to get to whatever particular location? They go, oh man, it takes 10 minutes. Then you go to get there and it takes 25. You’re like, what? They’re telling you often 10 minutes to make an enticing, but also to say, Hey, if it’s perfect traffic, maybe I want to know exactly, so let’s make sure we’re documenting it right by telling me how much time.

Whether it’s total minutes or from and two, what’s unacceptable, and this is where you have to be careful. Don’t state doing one unit. You can state that, but then you have to define one unit by how much time, don’t indicate a range. You can’t say, Hey, I spent somewhere between six and 18 minutes. It has to be a certain number.

It can’t be a range. It also can’t be, Hey, I just did it times two. What do you mean by times two? , and then of course, not just indicating any time by just saying, Hey, I circled acupuncture. A set massage. That would not be adequate. So by example, let’s take a look at this. If I’m doing acupuncture and I spend 10 minutes on the first set, that would be billable.

I circled to say that would be one set. What if I add an additional set in there for another 10 minutes? Would that be billable? What’s the amount of time that we spent? 10 plus 10 of course is 20. What does that mean? Only one set is billable. Now obviously it’s too short. Now you’re gonna say, but Sam, it went over eight minutes.

Yes it did, but it didn’t meet the time for the second unit. What if I spent a little bit more time? Let’s take an example. What if I did acupuncture for 12 minutes face-to-face, and then the additional set I did for 12 minutes again that will be 24. Which means above the 23 minutes and I could build both sets.

In theory you could do 11 minutes on one and 12 minutes on the other. What I wanna focus on here is just be careful that you do have to add the time for cumulative amounts. So for tunes to be billed, we have to have that minimum. Which brings me to what we started with was talking about therapy.

What about time therapy when it comes to acupuncture? Now, if I’m doing infrared heat, doesn’t matter because infrared heat doesn’t have a time value. You either use it or you don’t use it. However. Let’s take an example here of acupuncture and you did 15 minutes on the first set, 10 minutes on the second, which I would say isn’t unusual.

Obviously the first set may take a little bit more time. I do want you to keep in mind though, the second set does include if you’re face-to-face, finishing the notes. So if I did 15 plus 10, good. Now I did another 10 minutes of massage. It meets the eight minutes, but let’s total this up. 15 plus 10 is 35 minutes total.

If I did 35 minutes, how many units are set can I bill? Based on the eight minute rule, what’s the min minimum time for three is 38. So this would mean this would not be billable for the massage. I would build a two sets of acupuncture. Now, you may ask Sam, why are you gonna build a two sets of acupuncture?

They have a higher value, so I would pick the ones with the highest value, but we cannot bill all three. If I were to bill all three, I would have to have spent somewhere either three more minutes on this set. Three more minutes on this, or three more minutes on the first one. The total time. has to equal 38, so be very careful.

This is where I see people run into problems. They forget to look at the cumulative nature. Think of it simply, if you were to do massage only for 35 minutes, could you bill that for three units? No, not enough. So it doesn’t matter that it would just be one service or multiple, but let’s take an example using the same idea.

We did 15 minutes of the first set, 10 minutes on the second, and then 15 minutes fully of massage. What’s the total time there? The total time is 40 minutes. This means all three services can be billed because the minimum time of eight minutes was hit for each, and the cumulative time was over 38 minutes.

So what I’d like you to think of is just start getting in the habit of these time services and units to do them in this way. Please, I hope you’re not looking going, oh, this is too complicated. It’s not at all. You’re just documenting the services you have done. And I want you to think of this way.

Documentation should be a way that someone can look back. and go what was performed on that visit, and I’m talking a complete risk management of this. What if a patient were to say, I don’t think you did all the services, or was, making an issue of money. This would be the way to make sure you’re gonna say no.

It’s all there. I would love for us to be in the habit of it. Frankly, I’m frustrated for some acupuncturists because your time is something you do a lot of with your patient, but because of your lack of documentation, when notes get reviewed or people make an issue, , we cannot defend it. So let’s just start putting the time down.

You’re spending it. Let’s meet it. So eight minutes minimum for 1 23 for two. Get in the habit of that, whether it’s acupuncture or therapies, will make your life simple. Now, keep in mind, Acupuncturists aren’t doing a ton of services. You know why most people go to an acupuncturist? To get acupuncture.

But isn’t it good sometimes to get some additional services? I know when I’ve gone, I’m a big lover of cupping. I find that’s really helped me with some shoulder issues. But also there are times where they’ve done some gua or deep tissue work, and I would say there’s ways that acupuncture stood that others don’t, that you might be doing slightly differently and maybe have a better outcome.

Don’t be afraid of additional services. Just simply document them. We wanna make sure you’re getting the patient the best care, but I also wanna make sure you’re getting reimbursed. That’s what we do at the American Acupuncture Council Network. We’re here to make sure your offices continue to thrive and make more money.

If you would love to have an expert to be on your staff, you know you can hire me for less than a dollar a day. You can zoom with me. We can do one-on-ones where we go over your fee schedule, audit your files, make sure everything’s compliant with the big issue of not so much compliance but reimbursement.

Your practice is going to continue to thrive because of your ability to run it as a business. Allow us to help you do that. Take a look at the American Acupuncture Council Network. We’re here to help. Until next time, everyone, I wish the best, continue to be that good person to all your patients. I’m counting on you.

Get Claims Paid The 1st Time You Submit Them

But let’s talk about making sure that when you are dealing with insurance or dealing with claims that you’re not getting these common errors and common denials that are so frustrating because we wanna make your life a little simpler.

Click here to download the transcript.

Hi everyone. This is Sam Collins, the coding and billing expert for acupuncture, the American Acupuncture Council, and you the profession. As always, we’re trying to make sure your claims are getting paid. You can make your life a little simpler and more profitable. and you can do what you like to do, which is care for patients.

Let’s go to the slides. Does that talk about common denials and how to correct them? What goes on for acupunc? Why do claims get denied? What are some of the common things that we see? The most common thing that I run into, and I deal a lot with this, I lecture every year to thousands of you, many of you’re members of our network service, and one of the issues we run into, you’ll get a denial that says, The plan is not covered and you think I did the verification.

How is this not covered? What happened? One thing I want to really implore you to do is make sure you understand the coverage the patient has. Often you will see coverage that will say, we cover acupuncture, and you think, great, you’ve verified it. They cover acupuncture. Then you send a claim and it comes back denied.

What do you do? First I’d look to make sure was it really covered or ask this question. If there’s coverage for acupuncture, must the provider be in network? A lot of plans do have acupuncture benefits, but only for providers who are in their network. So don’t be confused. Often you’ll call and hear all these great answers like, is acupuncture covered?

And when they say Yes, you hang up, or you hang up and say, great, that’s phenomenal. Then you send a claimant, it’s not paid. It’s because you didn’t ask that other. is the coverage for in or out of network providers. And then I would further ask this question, do you see my office as in-network or. , if you’re out of network, is there no benefits?

So let’s often make sure that the plan, you know what it’s covering. Also know the types of coverage that it has. What does it cover in the sense, does it cover acupuncture alone? Does it cover therapies? If you do therapies? So be careful. That is a common area of denial. Make sure you verify the coverage.

The other area that we run into lots of problems with are claim forms. We’ll get into those specifically, but how to fill it out. None of it is very. But there’s a couple unique things. If you don’t do correctly, will commonly come back and it’s very frustrating. What about just improper diagnosis?

That’s certainly an area improper use of A C P T code, if you will, but also just missing a modifier and you’re gonna wonder what modifiers do I need to do? Don’t give you a quick primer on that today to make sure we’ve got the right information, but also make sure you don’t run into the one where it says insufficient document.

Is, do I have enough information to make sure the claim gets paid well? Let’s talk about claim forms. What are some of the common things that I run into that offices have? When someone comes in, they’re gonna present an insurance card, and on that insurance card we’ll have their information for the claim.

That’s what goes to the top part of this claim. Whether or not it’s a standard or group health insurance plan, or maybe it could be Medicare under some circumstances, but nonetheless, check that off properly. But the bigger issue. Do I have the patient’s name proper? Please note it says here, patient’s name, last name, first name, middle initial, whatever it is, make sure it’s exactly as appears on the insurance card.

So often I’ll see denials because the patient will have a name that they’ll say, oh, just call me Patty. When on the card it says, Patricia, don’t put nicknames. Also, make sure you’re putting the exact insurance ID number. We will often see numbers transposed. Because it just goes in and makes a quick error.

So do make sure now, once we’ve got that set, that ends it, but it’s nothing more frustrating going, wait a. , what information do I have to have? And this is often concerned. Many times it’s gonna be the patient and you’ll indicate self, but what if it’s the spouse or the child? Often you’ll put the patient’s name here, but if the name is different on the car because maybe it’s a child or it’s the spouse’s plan, remember their information goes here as the insured’s id.

so be careful. Sometimes the patient may be different from the insured, though they’re both insured. It depends whose name is on the card. So don’t run into that common era. But here’s a big one that comes up quite a bit. What about block 14? When you’re filling out the 1500 form and block 14, it says, date of current illness.

And so many people look at that and say what does that mean? What do we put in? Were you gonna put the date generally of when the patient had the first symptom and or an injury? But often you might say This patient had an injury or this pain has been there for years. Obviously if I put something 20 years ago, they’re thinking why are you putting that date down if it’s a very old date, or it’s a type of a chronic condition that continuously flares up?

Always update this date to the date where the patient presents to the office. So it doesn’t always necessarily have to be a date of injury. It could be the date of the first visit, but do make sure it’s completed and put in this area. And one quick note, if you’re billing Anthem, Anthem is a little bit weird.

Anthem wants the date of the first symptom here, but they also want to block 15 the date of the first visit. So this could be a week ago, and this is today’s date because it’s the first visit. And then the qualifier you’re gonna put there is 4 54. I know a little bit odd, but 4 54, that’s gonna be Anthem policies.

Anthem policies seem to require that a little bit more than anyone else. Now, again, just Anthem. Now the other area that I commonly see, and this is really a big issue for acupuncturists, is not having a complete code. Do make sure if you’re using coding, make sure that code is complete. Often you might be using a code that’s a little bit old.

Remember, codes do update. Some codes are three digits, some could be as many as seven. So please make sure if you’re using any coding, assure your codes are correct with a number of digits. Notice this one for just pain. R 52 is just three characters, yet this sprained strain. Is all the way up to seven characters, so do make sure it’s the proper one.

But here’s one to keep in mind though. , it’s more important to know what codes are gonna be payable for acupuncture, and this is where things get tricky. Last time I did this class with you, we talked about specifically certain types of insurances, specifically Aetna, on what they cover. Let’s look at a few other ones.

Here’s the company, American Specialty Health, and as you’re aware, well aware, they manage a lot of particular companies, particularly Cigna, some of the Blues, some Aetna plans as well. And they use what I call , I don’t know, physical therapy or chiropractic end of coating for acupuncture in that they want the neuromuscular skeletal type pain things.

Notice the things that they cover, headaches, hip or knee pain with osteoarthritis, extremity pain with or without osteo osteoarthritis or mechanical irritation, and just other syndromes related to the joints in muscles back and neck pain. So you’ll notice that’s not including like abdominal pain in other internal symptoms.

It’s really musculo s. Except for nausea and vomiting. So no, for this plan, if you were to code abdominal pain, not gonna cover, but if you code low back pain, it will. Now also, keep in mind, some things could be tricky. If you’re ever dealing with a Medicare advantage plan, common denials are because you’re using the code thinking, oh, I need low back pain and put M 54 50, when in fact, for the Medicare plans, whether it’s Medicare, part B, or.

You have to have M 54 51 or M 54 59, so it’s good to understand the nuances of what’s covered. Here’s an example of a course, the one we went through last time, which is the Aetna plans. These are the codes they cover, which tells me if you bill these codes, they’re gonna pay you. Bill something not on the list, they’re not gonna pay you.

So it’s important to start to learn the nuances of what codes are covered or not covered. That’s one of the things that we cover in our seminars. Or more importantly, if we do one-on-one as a network member, I can go over with you. Here’s what Health Partners has, here’s what UnitedHealthcare has, cuz it’s important to know what codes are payable.

Nothing’s more frustrating thinking something is. and it comes back not covered all because you didn’t understand the codes that they require. Another area that commonly comes back is that hey, I build for four sets of acupuncture. . They only paid me for three. What’s going on? Or sometimes, maybe they paid me for one, depending on the plan.

Under the standard rules, and this is across the nation if you will, there’s something called the medically unlikely edits. And what, these are the maximum number of services that are payable per a visit, and this includes all types of chiropractors, physical therapists, and so forth in every code or service.

Has a maximum number of services or units that they will allow. In this case, for acupuncture, it is three. They allow up to three. So if you bill more than three, they’re not going to pay it. They’re simply gonna bundle it. So do keep in mind it’s three, I’m sure you’ve seen as if you’ve ever dealt with the va, Cigna, United, and many of them.

Now, are there some plans that may be. Sure I’m familiar with plans out of New York, particularly New York ship that will generally pay up to four. So I’m certainly gonna say, bill, what you do, but do understand some plans will max out at three. So that denial is simply one of just fruition. They just don’t allow any more than that.

So again, if you’re billing more than three, that could be an issue. The other issue for acupuncture though, Modifiers and denials. So you notice here’s a claim form someone with simple back pain. But notice there’s the acupuncture codes billed, but then notice there’s modifier 25 on the exam. This is probably the most common denial I get for acupuncturists, is Sam, they didn’t pay for my exam.

The first thing I’ll ask you is, did you bill with modifier 25? And most of the time the acupuncturist will say to me what do you mean by modifier 20? As soon as they say that I know the reason. Remember, anytime you bill an. With your treatment, any treatment, you have to put modifier 25 on the exam code because this demonstrates that this exam is above and beyond the day-to-day evaluation.

In fact, what it means is what’s printed in bold here, if and only if the patient’s condition requires a significant separately identifiable e and m service above and. The pre-service and post-service associated with treatment. Remember, acupuncture or treatment includes a little bit of an evaluation, so every day there is evaluation.

It’s small, but there is, Hey, how are you feeling today? Is it better? Is it worse? Maybe you’re doing some palpatory findings, tongue and pulse. That small exam is embedded into. the acupuncture code, and that is the reason we put modifier 25 is cuz what we’re stating is this exam is above and beyond what we do on a normal day to day.

and therefore is payable no 25 no money. So make sure it’s there. Now what about a plan that doesn’t cover an exam? That might be a bit unusual, but it depends on your contract. What if you’re contracted with a company like a UnitedHealthcare under Optum, where they pay you per diem? They don’t pay separately for exams because they bundle it all as one payment.

So do keep in. That sometimes it’s a contract issue, but other times it’s just the fact, did I have the proper modifier? Now, you’ll notice none of these other codes have any modifiers on it because it’s not needed. However, what about this last 1, 97, 1 40? I know some of you’ll say I wanna put modifier 59, truthfully, a modifier 59 to indicate a separate services never needed.

However, you will need for some. Modifier gp. Now, this is why I think sometimes acupunctures go, I don’t know if I wanna do insurance at all. It’s just too much hassle. It really isn’t. It’s just understanding the nuances of it. Once you understand it, it’s not hard. So now here’s the rule. If you’re billing United Healthcare, You’re gonna put a gp, G as in George, P as in Paul at the end of a physical medicine code.

So that’s all physical medicine codes, whether it’s from heat all the way through the unlisted service, but massage, manual therapy, you name it. And it’s gonna go on all of these payers, UnitedHealthcare, that includes Optum Health and everything affiliated U M R U P M R, VA claims will. Anthem requires it.

And if you’re in California, here’s a weird one. Blue Cross of California, not Blue Shield. And of course, any of the Medicare plans or federal plans you may do. So again, think of it, a denial will come back and you’re thinking, why didn’t they pay for a therapy? is because you were missing the modifier when it’s one of these policies.

So do keep in mind, focus in on making sure that I have the claim form right, and that’s one of the things I help with. That’s why I’m an expert. I’m here to help you to make sure that you do well and that’s what these short courses are for. Now, one thing to keep in mind, you’re thinking if I’m gonna put a GP.

I’m just gonna put a GP for everybody. Nope, do not blanket it. Don’t include it for plans that don’t require it. Only the ones that I’m showing here. And here’s the final thing I’ll get into is that it’s just INS insufficient information. And you’ll notice here it says, according to 9 7814, it’s not supported.

The medical records submitted do not indicate the needles were inserted and does not indicate the face-to-face time. Now this is something for another course, but do keep in mind if they look at your. Can they tell what you’ve done? Now, here’s something interesting about this claim. You’ll notice the initial set is paid.

They’re saying it was supported, it was the follow-up set. So you gotta start to look at your notes and go, wait a minute, do my notes demonstrate what I need? Do I have the face-to-face time? Does it meet the minimum standards for each individual set? So that includes first set in multiple sets. And again, we need the time face to.

As well as the points of insertion. None of this is hard. Let’s face it, it can seem daunting if you’ve never done it. Once you get a good feel for it, you’re gonna go, wow, that’s really easy. I want you to think of, you sometimes will say, I don’t think I want to take insurance, cuz there’s these hassles. Do you realize the majority of people have insurance and they have acupuncture coverage?

Don’t you think they’re gonna want to use it? I want to give them access. What I have to do is make it simple. That’s what we’re here to. That’s what these courses are for. And that’s it. If you wanna really get some one-on-one help where we work together, we zoom directly one-on-one. You can even go to our seminars for free.

Take a look at the American Acupuncture Council Network. We’re here to support you. Your success is ours. Until next time, my friends.

Aetna’s Mandatory Acupuncture Benefits

Click here to download the transcript.

Hey, greetings all, it’s Sam Collins. You’re coding and billing expert for acupuncture in the American Acupuncture Council. Most importantly, for the profession and for you. Let’s always work on getting your office. to be the most profitable in business that we can. I’m the expert when it comes to coding and billing, which means also though, for payment and how do I make my office survive?

And it’s not just insurance. It could be cash, and we work a little bit on all those. But today, let’s focus on what’s going on with insurance coverage, particularly with the company Aetna. It’s at some nice changes, but it’s important to know though they’re increasing or having mandatory. , what do they actually cover?

One thing that you have to be careful of is understanding what codes they will pay or will not pay to make sure and assure that your claims get paid. Frankly, make sure the patient gets the best benefit and you’re paid for your services. So let’s go to the slides. Let’s talk about this acupuncture under Aetna.

And its mandatory coverage, but what does it cover is what I’ll say. Well, let’s talk about where Acupuncture’s really move or has moved. There’s a much broader access to acupuncture. Why does that happen? Frankly, it’s consumers who want it realize that the additional coverage that people are getting is because the want of customers out there who want it.

In fact, you’ve probably seen some of the commercials for the Medicare Advantage plans that literally use acupuncture as a way of marketing, so consumers are looking for it. Obviously, insurers. Why are insurers looking at it? Well, they’re realizing it helps, saves. But it also is sort of mandated based on opioids and some other issues.

So we’re seeing access there. Obviously the Affordable Care Act has helped because it’s made mandatory in five states, but now there’s been two that have been added. So for those of you who are in Oregon and Colorado, you now have also mandatory acupuncture benefits on all plans under the Affordable Care Act.

So that’s a good thing. That’s in addition to the other five states. Of course, the VA has created. . That’s nice. Medicare has not quite where we want it, but we’re getting there. And of course the big thing is the opioids have probably created most of that to be there. Why? Well, let’s take a look. 37 State Attorney Generals of National Governance Association have now endorsed and say they want more acupuncture.

They need it to be included. Why? There’s a few issues. For the most part, it’s just a money saver. If you go to an acupuncturist, that’s $600 compared to a primary doctor, which is 17. In addition, when a person contacts an acupuncturist, 30% of the cases compared to 70%, they’ve done the work. When people go to an acupuncturist first, it will save Medicare 230 million in its medical budget per year.

That is a big change and a big money maker. So insurance companies are starting to pay attention. The American College of Physicians for back treatment guidelines now indicate acupuncture. Even the FDA now says, Hey, for non-pharmacologic people should be doing acupuncture. There’s a bill going through Congress now in California to specifically make sure that there’s always access to acupuncture for people that are gonna need opioid.

To know they have that access, that there is something beyond taking an opioid. Well, even the CDC has gotten on board saying, Hey, when prescribing opioids, clinicians have 12 recommendations for acute subacute acupuncture. Non-pharmacological has gotta be part of that. They highlight the benefits, the effectiveness of it, and health insurance should continue to improve that because creating more access saves everyone, not including the people who take opioids and can overdose The CDC guidelines now, all specifically all.

about acupuncture. So I think what we’re seeing with a company like Aetna is what they’re doing is creating where people have more access. So you’ll see here in 2022, Aetna is added standard acupuncture benefits and new and renewing commercial health plans. So anyone who has Aetna through their job commercial plan, is going to have now acupuncture benefits.

That’s really cool. Aetna’s always had acupuncture benefits for some plants, but not all. And I’m sure some of you’ve run into that. You’re thinking, oh, it’s covered. Then it comes back, oh, it’s not covered cuz we only cover it for, you know, uh, this, uh, surgeries if you will for, uh, anesthesia, that type of thing.

Now it’s gonna have a standard coverage, which means all plans have it. So here’s the good news. If someone has. Do they have acupuncture? They do. In fact, it’s governed under their acupuncture and dry needling guidelines, which is their clinical policy bulletin, and it says, now standard NAPLANs STEM coverage of acupuncture for medically necessary indications.

So now here becomes the difference because it’s covered. Does that mean they cover everything an acupuncturist could diagnose or. No it doesn’t. It’s still limited, but that still means there’s a lot of access here. So they’re gonna limit it to the coverage things that they do. Now, this is what I wanna be clear on.

You wanna know what codes they will or will not pay for. This is what we do with our seminars. This is what we do for my network members to make sure you’re updated. So you’ll notice here the next review was just this year. They haven’t published it yet. We probably won’t get any updates to this probably until June or July.

I’m not sure it’s gonna update very much, but it’s going to follow along these lines. And it’s very specific about what it covers and you’ll notice it gives about 10 things that it will cover. It covers when medically necessary neck pain. It covers headache. Now those are relatively new. It used to not cover those, but it does say chronic.

So kind of that it’s been there for 12. Now, I think for many patients, chronic conditions like this aren’t hard to muster simply because it’s not always an acute issue, but a patient will go, I’ve had these headaches on and off for months. Well notice also it covers low back pain. Well notice it doesn’t say chronic low back pain, which now means it can be acute as well.

It also includes nausea of pregnancy, osteoarthritis of the knee or hip. So knee or. Does it cover arthritis? Are there is No, they’re saying near hip. So near hip pain. It also covers nausea from, um, chemotherapy. So, so-called chemotherapy-induced nausea, dental pain, which is kind of weird. So they, are you telling me that Aetna will cover for someone that has tooth pain?

Maybe they’re getting a tooth removed or something? Yes, they will. Not. Through their dental insurance, through Aetna, they also covered TMJ conditions. Now that’s something unique to them, CIG. Has a much broader allowance of diagnosis. But do you know Cigna doesn’t cover TMJ yet? Aetna does. So here’s what I will tell you.

If you code within this range, they’re gonna pay you you code with these conditions, they’re definitely gonna pay you. Just be careful of maintenance treatment. Notice what they define as maintenance treatment. Maintenance treatment where the member’s symptoms are neither regressing or improving is considered not medically necessary.

So I’ll simply put it this. , so long as you’re making the person better, it’s medically necessary. Now, the difficulty is once they are better, should we keep treating to keep them that way? My opinion? Yes. However, from an insurance standpoint, they want them to have a fall off and when they do, can treat again.

So this is where you might see a patient periodically throughout the year for acute episodes of a chronic condition. It flares up, we take care of it. We do a handful of visits if they’re. A month later it comes back again. But will they cover it? The answer is yes. Now they’ve listed the conditions, but what are the codes?

So let’s take a look at these codes specifically. They cover headaches and it covers migraines. Now you’ll notice migraine headache is G 43 0 0 1 through G 43 9 19. So you can well imagine. Wow, there’s a lot of coats from migraines Now there’s not 900. There is about 35, but they vary between those sections.

The most common one, G 43, 1 0 9, that’s your standard run of the mill migraine. But does it cover migraines? It does. Does it cover tooth pain? It does, but look at the code K 0.89. I bet many of you’ve never seen that. That’s literally a code that says disorders of the teeth. But because there’s no specific code for tooth pain, we use this one to document that in the notes.

It’s gonna have pain, but this is the code you use. It will also cover arthritis, but notice it’s arthritis of the hip, the hip, the hip, the knee. The knee, the knee. So it’s covering hip and knee pain. Now, you know what frustrates me about that? If you can tell me that acupuncture is gonna help with the knee and arthritis, pain of the knee, or.

Why would that not work in other areas of the body, such as the shoulder or the elbow? I think it obviously would, but again, they’re specifically indicating here it does indicate TMJ disorders, so TMJ dysfunction of any type or pain notice, neck pain, and then the low back pain codes. Then of course, vomiting of pregnancy, vomiting, chemotherapy, headaches, and that adverse ad, adverse effect of anti-neoplastic immunosuppressive drugs.

And notice, parenthetically, it says chemotherapy-induced nausea and vomiting. The fancy term is adverse effects, but it’s just chemotherapy-induced nausea. One quick note, this code has a plus at the end. Please note that this code any, anytime it’s an S or a T, prefixed to a code, it always ends in an A for acute.

And then the last one says Other specified post-procedural status. This is the code for post-surgical pain. They’re specifically indicating it dental, but obviously if you’re using any other type of post-surgical, this could work. One quick note please. Everyone take note of this, this code Z 98.89, even though it was published this way by.

it’s incomplete. It actually should be Z 98.890. So do write that down. Z 98.890, not 89. It shows you that insurance companies aren’t always infallible as well. But here’s what I’ll point out. If you code these two Aetna, I am going to guarantee they’re gonna make payment because these are on their list.

In fact, at the very top it says, these are the codes. If the selection criteria is met, which means is it chronic pain in some areas or is it, you know, manifesting that way. But you’ll notice they do something tricky. They say, parenthetically not all inclusive. Now that frustrates me because what they’re saying is these are the codes we cover.

We may cover more, but we’re not gonna tell you. Well, what I will tell you is generic. There’s some additional things that they’ll cover, and two of them, one of them is really gonna surprise you. I talked about the knee and hip arthritis and pain. What I will tell you is arthritis wise, they’ll cover here.

They’ll also cover pain. I have found through many people that pain in a joint will be covered like shoulder, elbow, wrists, so you’re pretty safe there. What they will also cover surprising. is anxiety. Now not full on depression. We’re not coding that probably from an acupuncture standpoint, but anxiety, depression, unspecified.

The code for that is F, as in Frank, 41.8. Now I’m pointing these out the other joint and this, um, anxiety just to say these are some other services. Some of you may say, Hey, Sam, I build a few other ones and they’ve been paid well. Great. I would like to say, let’s look at those and make sure we all know what they are.

That’s why I gave you those three extra ones, meaning joint pain and then of course the anxiety. What I will focus on though is to tell you be careful of coding things they don’t cover by example. You’ll see here it says Cervi. . That means neck pain. Now what if you have someone that has a strain of the neck?

You know, they do something active and they strain or sprain the muscle. If you coach strain or sprain to Aetna, they will deny the claim even though it’s neck. So what should you do? Don’t coach. Strain. Sprain. What? What is the symptom? What are the complaints a patient will have when they strain their neck?

You got it. Neck pain. So in this way, you’re gonna use the more generic, just tell me where the pain is. Don’t get specific that it’s spondylosis or other things of that nature. I kind of like that. It does keep it simple, but here’s what I’m again gonna point out. Make sure you’re looking at this list and if it’s not on the list, Make sure that you can find someplace that, okay, I’ve seen this elsewhere been covered.

This is one of the things we do at our seminars. More importantly, our network service. When members call me or get in touch with me, this is what I help them with is that here are the additional codes they may cover. I wanna at least give you a thumbnail though, to see what they do cover. So when they say they have mandatory coverage, I’m gonna say, yes, they do, but it’s for these codes.

So maybe take a picture of this screen, make sure you’ve got the right ones. What do they cover? Well, they cover acupuncture as you can. Well see, you know, initial sets, follow up sets where they’re manual electrical. But you’ll notice it also says tending the TDP lamp. No specific code. It says, well, what would that be though?

That’s probably just gonna be your hot lap. 9, 7, 0, 26 notes. It also covers dry needling. Will it pay an acupuncturist for dry need? Generally, no. What they’re gonna cover you for is acupuncture. I’m not gonna say an acupuncturist can’t dry needling, but I would assume it’s more acupuncture. These are the things they’re gonna pay you for, and quite frankly, they have a higher value.

I’ve had people ask me, Sam, can I bill dry needling? Well, I guess you could, but here would be my point. Why would you? The value of the dry needling codes are 50% of the acupuncture codes. Why would I bill a service that’s 50%? Than the actual service I’m performing. So I would focus in on the acupuncture.

Think of it, and this is something I emphasize when I come to you as a patient or when someone comes to you, guess what they’re seeking acupuncture. Therefore, what should you provide? Acupuncture. That doesn’t mean you might not do a little body work or some other things, but notice they’re not indicating these are covered.

I’ve run into some issues also where offices have had some plans with Aetna that don’t cover the. Now if the plan doesn’t cover it, does the patient have to pay for it? Well, they would assuming you’re out of network. But keep in mind, what I will tell you they will pay is the acupuncture codes. Now, be careful, stick with the codes I gave you because here’s their list of things they don’t cover, and look how far this is.

We have acne, pancreatitis, addiction, aids, Alzheimer’s, all of these conditions. If you code any of. , it won’t be covered, but let’s take this one here. Notice it says myofascial pain. Okay. What is myofascial pain? Pain in the muscles in some part of the body. Well, what if those pain in the muscles are in the neck?

How would you code it for Aetna neck pain? What if they’re in the low back, low back pain, and so forth. So in some ways, these things can be covered, like by example, carpal tunnel syndrome right here. What does carpal tunnel syndrome cause? Wrist pain or forearm pain, that’s what we code. So be careful they’re not covering these things, but they may cover it if you can keep it symptomatic.

So while I will say, I’m happy to see this, I hope it gets better, this gives us a good framework so that way you’re not fooling yourself. One of the difficulties that I’ve run into offices is they’ll say, Sam, my claim’s not being paid in its Aetna. Then they send me over and they’re coding something that’s not on the.

and I say to them, let’s make a correction. So these are the things that I wanna make sure that you understand that you can solve that if a patient comes in with a condition that clearly doesn’t relate to any of those, you know what you’re gonna tell them. This is not covered by your plan. However, here’s what we offer for cash patients, whether you’re doing a pre-pay plan or just a discounted time of service, that might be something you can do.

But I don’t want a patient thinking it’s covered and it’s not. Cuz do you ever notice, sometimes people wanna blame. when you are, when their insurance doesn’t cover, how is that your fault? It’s not. Obviously it’s their coverage and so don’t give them the false sense that it is covered. This is what we do at American Acupuncture Council, specifically the network.

You want someone to be helped to you. I’m an expert. I could become part of your team. Join us. You can call me, you can email. We do Zoom. We are here to make sure you’re getting. Many of you have lots of problems of things that don’t pay you we’ll fix that. Take a look. Otherwise everyone, I’ll see you next time.

Until then, I wish you the absolute best and continue doing what you’re doing. Take good care of your patients.