Acupuncture practices face ongoing challenges when it comes to insurance billing. The 97810 CPT code is the foundational code for acupuncture services, which covers the initial 15 minutes of a patient’s visit.

Understanding how and when to use the CPT code 97810 code, along with related codes, is essential for maximizing insurance reimbursements and improving revenue flow for your practice.

In this blog, we’ll cover the basics of the 97810 code, discuss the intricacies of related CPT codes, offer tips on proper documentation, and share best practices for ensuring you receive maximum 97810 CPT code reimbursement.

Understanding the 97810 CPT Code

CPT Code 97810 is specifically designated for the first 15 minutes of initial acupuncture treatment with one-on-one patient contact. This code represents the foundation of billing for acupuncture services. Here’s a breakdown of what it covers:

• Initial 15-minute session, including both assessment and needle insertion.
• Direct patient interaction—time spent must be face-to-face.
• It’s used for the primary acupuncture treatment and cannot be combined with codes meant for additional units (unless there is a separate and distinguishable service provided).

According to AAPC, the 97810 CPT code description is:

Acupuncture, one or more needles: without electrical stimulation, initial 15 minutes of personal one-on-one contact with patient.

This code, when used correctly, ensures reimbursement for the time and care given during the initial part of the acupuncture session.

Tip: What is 15-minute increment?

In acupuncture billing, the initial 15-minute session refers to direct, face-to-face contact between the acupuncturist and the patient. This time is counted only when the acupuncturist is actively performing activities essential to the acupuncture treatment, such as needle insertion, assessment, or adjustments. The time does not include any period when the needles are simply retained in the patient after insertion. Only the time spent on hands-on treatment contributes toward the reimbursable 15-minute increment.

• 1 unit (set) must include a minimum of 8 minutes face to face time with insertion (8-22 minutes = 1 unit)
• 2 units (sets) must be at least 23 minutes face-to-face time with a 2nd set applied after the 15th minute (23-37 2 units)
• 3 units (sets)must be at least 38 minutes face-to-face with a 3rd set applied after the 30th minute (38-52 = 3 units)
• 4 units (sets) must be at least 53 minutes face-to-face with a 4th set applied after the 45th minute (53-67 = 4 units)

Related CPT Codes for Acupuncture Treatments

Maximizing reimbursement often involves utilizing additional CPT codes correctly. Here are the related acupuncture CPT codes that can be used in conjunction with 97810 acupuncture CPT code for extended treatment times:

• 97811: Used for each additional 15-minute increment of acupuncture, with reinsertion of needles, after the initial session billed with 97810. This code should only be used if the session extends beyond the initial 15 minutes and involves further needle insertion.
• 97813: Acupuncture with electrical stimulation, initial 15 minutes, one-on-one patient contact. This code applies when electrical stimulation is used in addition to acupuncture, providing a higher reimbursement rate due to the additional equipment and setup involved.
• 97814: Each additional 15 minutes of acupuncture with electrical stimulation, following the initial 15 minutes billed with 97813. This is used for longer sessions with continued electrical stimulation.

Using these codes in the correct combination helps acupuncture practices capture the full extent of the services provided during a session.

To help you better understand acupuncture billing process, we have created a complete guide to Acupuncture Billing and Coding to help you maximise your insurance reimbursements. Download it here.

Best Practices for Maximizing Reimbursements with 97810 and Related Codes

Acupuncture billing requires attention to detail, especially when using the 97810 billing code alongside related codes. Below are some of the best practices to help maximize reimbursements:

a. Accurate Documentation

Clear and accurate documentation is essential for avoiding claim denials. When using 97810, document the following:

• Patient’s chief complaint and relevant medical history.
• Details of the acupuncture treatment, including areas treated, number of needles used, and any specific techniques applied.
• Total face-to-face time with the patient, broken down by initial and additional increments.

Document these details to provide insurance reviewers with a clear understanding of the treatment provided and helps ensure the claim is processed smoothly.

b. Clear Time Tracking

Since the CPT code 97810 is time-based, it’s crucial to record the time spent on each aspect of the acupuncture session accurately. Note that:

• 97810 CPT code covers the first 15 minutes.
• Additional increments must be at least 15 minutes each to qualify for 97811, 97813, or 97814.
• Break down time spent on evaluation, needle insertion, and monitoring to ensure each segment is clearly documented.

Accurate time tracking supports the claim and provides clarity on the services rendered, preventing denials due to insufficient documentation.

c. Medical Necessity

Reimbursements are often contingent on the medical necessity of acupuncture treatments. To establish medical necessity:

• Include detailed patient notes on symptoms, severity, and how the treatment addresses specific medical issues.
• Reference any previous treatments that were unsuccessful, highlighting why acupuncture is a necessary and beneficial option.
• Ensure that documentation reflects ongoing need for treatment, especially for chronic or complex conditions.

By clearly justifying the medical need for acupuncture, your claims are more likely to be approved by insurance providers.

Common Challenges and How to Overcome Them

Billing acupuncture treatments with 97810 billing code and related codes can be challenging due to insurer requirements and specific documentation standards. Here are some common issues and solutions:

a. Denials Due to Insufficient Documentation

• Solution: Include detailed notes on the treatment provided, documenting every 15-minute increment and noting each change in treatment approach. 

b. Limited Coverage for Acupuncture Services

• Solution: Prior to treatment, verify each patient’s coverage details, including specific CPT codes covered and any policy exclusions. This can prevent denied claims and help set clear payment expectations with patients. 

c. Misinterpretation of Time-Based Codes

• Solution: Train staff to accurately track and record treatment times for each code. Emphasize that each increment must be a full 15 minutes to qualify for additional CPT codes.

Additional Tips to Boost 97810 CPT Code Reimbursement

Here are some extra tips that can make a difference in your reimbursement rates for acupuncture services:

a. Educate Patients on Insurance Coverage

Many patients are unaware of what their insurance covers for acupuncture. Educating patients about their benefits can:

• Reduce confusion or frustration about out-of-pocket costs.
• Increase their willingness to consent to ongoing treatments, knowing their coverage details.

b. Keep Up-to-Date on CPT Code Changes

Insurance companies periodically update their policies and billing guidelines. Staying informed about any changes to CPT codes and reimbursement policies can help prevent denied claims. Regular training and updates for billing staff are also recommended to keep them aligned with the latest coding practices.

c. Avoid using both CPT codes 97810 and 97813 together

Never combine 97810 and 97813 on a single claim for acupuncture services, as both codes refer to an initial 15-minute session involving the insertion of one or more needles. Using both in the same claim may lead to billing issues because they both represent the initial treatment phase. Instead, select one of these codes based on the specifics of the treatment provided.

For accurate and compliant billing, consider the following code combinations where medically necessary and appropriate:

• 97810 (Initial 15 minutes of acupuncture) with 97811 (each additional 15 minutes of acupuncture without electrical stimulation)
• 97813 (Initial 15 minutes of acupuncture with electrical stimulation) with 97814 (each additional 15 minutes of acupuncture with electrical stimulation)

These combinations ensure that the coding accurately reflects the type and duration of treatment while aligning with reimbursement guidelines.

Example: How to Bill for a Typical Acupuncture Session

Let’s look at a typical scenario to see how the 97810 and related codes might be used:

Scenario: A patient visits for acupuncture to address chronic lower back pain. The acupuncturist begins with a 15-minute initial session and then continues with two additional 15-minute increments.

• Code 97810: Billed for the first 15 minutes of acupuncture.
• Code 97811: Used twice for the additional 15-minute increments.

This breakdown would allow the practitioner to capture the full time spent on the treatment while maximizing reimbursement potential.

Conclusion

The CPT code 97810 is crucial to billing for acupuncture services, but fully maximizing reimbursements requires strategic use of related codes, precise documentation, and diligent time tracking. By implementing these best practices, acupuncturists can increase their likelihood of full reimbursement and streamline their revenue cycle. With accurate coding and an understanding of insurance requirements, your practice can avoid common pitfalls and maximize revenue from acupuncture services.

Stay proactive, educate your team on the latest billing guidelines, and ensure each session is well-documented. This will help you build a consistent, predictable revenue stream for your acupuncture practice.

Maximize Reimbursement with zHealth Acupuncture Software

zHealth Acupuncture Software can help you maximize reimbursements with ease and efficiency. With an integrated billing software, zHealth automates your billing workflows, ensuring you’re not missing out on revenue opportunities. Schedule a free consultation with our team to learn how our software can streamline your billing process, reduce denials, and boost your practice’s financial performance.

Related Articles:

Avoid These Common Mistakes With Acupuncture Billing Codes

Acupuncture CPT Codes For Insurance Billing 2024

Top Reasons Why Your Clinic Is Not Getting Paid For Acupuncture Services