Acupuncture billing practices require precision and clarity, especially when dealing with insurance companies. Accurate billing ensures that providers are reimbursed for the services they provide.
Importance of Understanding CPT Codes in the Healthcare Industry
CPT (Current Procedural Terminology) codes play a pivotal role in healthcare billing, enabling clear communication between providers and insurance companies. Accurate coding ensures proper compensation and reduces claim denials.
CPT codes are the backbone of acupuncture medical billing, providing a standardized language for healthcare services. Understanding and correctly applying these codes is crucial for avoiding claim denials and ensuring financial stability in practice operations. One of the most commonly used CPT code in acupuncture practices is 97813. In this blog, we will explore
What is the 97813 CPT Code?
CPT 97813 refers to acupuncture services with electrical stimulation. This includes inserting acupuncture needles into anatomical sites and applying electrical currents to enhance therapeutic effects.
According to CMS, the CPT code 97813 definition is:
“Acupuncture, 1 or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.”
In accordance with the CPT code 97813 descriptions and/or the Centers for Medicare and Medicaid Services (CMS) guidelines and National Correct Coding Initiative (NCCI) established Medically Unlikely Edits (MUE) values, the maximum units of Acupuncture services billed under 97813 and other related CPT codes allowed per date of service are as follows:
| CPT Codes | MFD Value |
| 97810 | 1 |
| 97811 | 2 |
| 97813 | 1 |
| 97814 | 2 |
| S8930 | 3 |
Also, according to UnitedHealthcare’s 97813 CPT code description, acupuncturists can report one initial CPT code, 97810 or 97813, per day.
Specific Services Covered Under This Code
- Initial acupuncture session with electrical stimulation.
- Services provided during face-to-face time with the patient.
- Needle insertion and stimulation procedures.
Other Related CPT Codes
- 97810: Acupuncture without electrical stimulation, initial 15 minutes.
- 97811: Acupuncture without electrical stimulation, subsequent sessions.
- 97814: Acupuncture with electrical stimulation, additional sessions.
Challenges of Using CPT Code 97813
1. Navigating insurance policies and staying compliant with varying payer requirements can be daunting. Incorrect billing and usage of 97813 acupuncture code due to misunderstanding coverage limitations often leads to claim denials.
2. Practitioners sometimes miscode acupuncture services, leading to denied claims or reduced reimbursements. Proper training in coding can prevent such issues.
3. Many insurance plans have limitations on acupuncture coverage, requiring practitioners to justify medical necessity or submit additional documentation.
Optimizing Reimbursement for 97813 CPT Code
Reimbursement for acupuncture services can be a complex process, especially when dealing with insurance companies. Implementing effective strategies for 97813 CPT Code can ensure that practitioners receive fair compensation for their services while maintaining smooth operations.
1. Thorough Eligibility Verification
- Verify patient insurance coverage before providing services. Confirm if acupuncture and electrical stimulation are covered and identify any policy limitations or requirements.
- Obtain preauthorization when required, especially for procedures involving CPT 97813.
2. Developing Comprehensive Treatment Plans
- Clearly outline the medical necessity of acupuncture with electrical stimulation. Include details such as the diagnosis, expected outcomes, and the frequency of treatments.
- Use evidence-based practices to demonstrate the effectiveness of the treatment for the patient’s condition.
3. Fee Schedule Optimization
- Regularly review and update your practice’s fee schedule to reflect the current market rates for 97813 acupuncture code.
- Ensure that your fees align with those of comparable practitioners to avoid underbilling.
4. Building Relationships with Insurance Payers
- Maintain open communication with insurance companies to stay updated on their coverage policies and documentation requirements for CPT 97813.
- Advocate for higher reimbursement rates during contract renewals by presenting data on the efficacy and patient outcomes of acupuncture with electrical stimulation.
Important Things to Keep in Mind When Using CPT Code 97813
a. Consistent with the CPT code description and the CMS NCCI Procedure to Procedure Coding Edits (PTP), electrical stimulation services (97014 and 97032) should not be reported in addition to specific Acupuncture services that include electrical stimulation (97813, 97814, and S8930) as these are mutually exclusive procedures.
b. Acupuncture codes 97813, 97814 and S8930 are considered inclusive to G0283. A modifier may be appropriate when an electrical stimulation service is performed distinctly and separate from the Acupuncture service and the documentation supports the service was not related to the Acupuncture.
c. Effective January 1, 2024, CMS has updated its guidelines for acupuncture and dry needling services as follows:
- Acupuncture Sessions: Each session will include one initial acupuncture HCPCS code—either 97810 or 97813 billing codes —regardless of whether it is combined with any applicable add-on codes (97811 or 97814) on the same date of service (DOS).
- Dry Needling Sessions: HCPCS codes 20560 or 20561 will count as one session for dry needling on the same DOS.
Mistakes to Avoid When Using 97813 CPT Code
CPT Code 97813 is essential for billing acupuncture services involving electrical stimulation. While it offers significant opportunities for accurate reimbursement, practitioners must be vigilant to avoid common pitfalls. Mistakes in coding and billing can lead to claim denials, delayed payments, or compliance issues. Below are the critical mistakes to avoid when using CPT Code 97813 and tips to ensure proper billing practices:
1. Incorrect Code Application
One of the most frequent errors is applying the wrong CPT code to the service provided. Practitioners might mistakenly use 97813 for standard acupuncture without electrical stimulation, which should be billed under CPT codes 97810 or 97811.
How to Avoid:
- Ensure that electrical stimulation is indeed part of the treatment before selecting CPT 97813.
- Train staff to distinguish between acupuncture with and without electrical stimulation.
2. Failing to Verify Insurance Coverage
Insurance policies vary widely in their coverage for acupuncture services. Some plans may have specific restrictions or require prior authorization for services billed under CPT 97813.
How to Avoid:
- Verify the patient’s insurance coverage and benefits before the session.
- Confirm if the payer requires pre-authorization or additional documentation for acupuncture services involving electrical stimulation.
3. Lack of Proper Documentation
Insufficient or inaccurate documentation is a leading cause of claim denials. To justify the use of CPT 97813, practitioners must clearly document the inclusion of electrical stimulation in the acupuncture session.
How to Avoid:
- Record the acupuncture points targeted, the type of stimulation used, and the duration of the session.
- Use templates or electronic health records (EHR) systems that prompt practitioners to include all necessary details.Overlooking Coding Guidelines and Updates
4. Overlooking Coding Guidelines and Updates
Healthcare coding guidelines are frequently updated. Using outdated codes or ignoring payer-specific guidelines can result in rejected claims.
How to Avoid:
- Stay informed about changes to CPT codes and payer policies.
- Attend coding workshops or subscribe to industry updates to remain compliant.
5. Submitting Claims for Non-Covered Services
Billing for services that are not covered under the patient’s insurance plan can lead to denials and unnecessary administrative work.
How to Avoid:
- Clearly understand what services are covered under the patient’s plan.
- Educate patients about their financial responsibility for non-covered services before providing treatment.
6. Billing Acupuncture and Dry Needling on the Same Date of Service (DOS)
CMS explicitly prohibits billing acupuncture and dry needling codes on the same DOS. Submitting such claims will result in rejections.
How to Avoid:
- Review CMS guidelines and ensure that only one type of service (acupuncture or dry needling) is billed per DOS.
- Train billing staff to flag potential conflicts before claim submission.
7. Incorrect Use of Add-On Codes
Practitioners sometimes misuse or omit the appropriate add-on codes (97811 or 97814) for subsequent units of service.
How to Avoid:
- Understand the correct use of add-on codes for additional acupuncture services during the same session.
- Include all necessary documentation to justify the use of these codes.
8. Inadequate Patient Education
Failing to inform patients about the billing process or insurance coverage can lead to disputes or dissatisfaction if claims are denied.
How to Avoid:
- Discuss the scope of services, associated costs, and potential insurance limitations with patients beforehand.
- Provide written estimates for services not fully covered by insurance.
9. Neglecting Compliance with Audit Requirements
Acupuncture services are frequently subject to audits, and inadequate documentation or improper coding can result in penalties.
How to Avoid:
- Maintain thorough, accurate, and up-to-date records of each session.
- Implement internal audits to review claims before submission.
10. Not Following Payer-Specific Rules
Each insurance payer may have unique rules for coding, documentation, and 97813 CPT code reimbursement. Ignoring these can cause claim denials.
How to Avoid:
- Familiarize yourself with the billing policies of each payer you work with.
- Customize your billing practices to align with individual payer requirements.
Conclusion:
Proper use of CPT Code 97813 can significantly enhance billing efficiency for acupuncture services within chiropractic practices. By focusing on accurate documentation, patient education, and staying updated with industry changes, practitioners can minimize claim denials and optimize reimbursements. Regular training for practitioners and staff ensures compliance with the latest guidelines and contributes to improved practice profitability.
By leveraging zHealth, acupuncturists can save time, reduce errors, and focus more on delivering quality patient care while ensuring a seamless billing workflow and maximum 97813 CPT code reimbursement.
Related Articles:
Simplify Billing: Steps To Boost Collections For Acupuncturists
A Complete Guide To Acupuncture Billing And Coding
Emerging Trends In Acupuncture Practice For 2024
Avoid These Common Mistakes With Acupuncture Billing Codes
