Acupuncture has gained significant recognition and popularity in modern healthcare. As more people in the USA seek alternative and holistic treatment options, acupuncturists have witnessed a rise in patient demand. To ensure fair reimbursement and financial sustainability, it is crucial for acupuncture practitioners to navigate the complex world of insurance billing. In this blog post, we will delve into the current acupuncture CPT (Current Procedural Terminology) codes for insurance billing in 2024, providing valuable insights to help providers streamline their billing processes and maximize reimbursements.

Understanding CPT Codes for Acupuncture

CPT codes for acupuncture are standardized numeric codes used to describe medical procedures and services provided by healthcare professionals. They serve as a universal language for healthcare providers, insurance companies, and government agencies to communicate and track services rendered.

Acupuncture CPT Codes for New Patients

When it comes to returning patients in your acupuncture practice, it’s important to accurately document and code their evaluation and management services. The following acupuncture billing codes can be utilized for existing patients who have received professional services from you or another practitioner within the same specialty connected to your practice in the last three years:

99211 – Evaluation/Management (Minimal):

This CPT code for acupuncture is applicable when the presenting concerns are minimal. Typically, the provider spends about five minutes in face-to-face interaction with the patient.

99212 – Evaluation/Management (Limited):

When the presenting concerns are self-limited or minimal, this code is used. It involves a problem-focused history, a problem-focused examination, and straightforward decision-making. The practitioner typically spends around 10 minutes in face-to-face interaction with the patient.

99213 – Evaluation/Management (Expanded):

For patients with difficulties of low to moderate severity, this code is appropriate. It requires an extending problem-focused history, an expanded problem-focused examination, and medical decision-making of medium complexity. The provider usually spends approximately 15 minutes in face-to-face interaction with the patient.

99214 – Evaluation/Management (Detailed):

When the existing problem(s) are of moderate to high severity, this CPT code for acupuncture is used. It entails a detailed history, a detailed examination, and medical decision-making of moderate complexity. Physicians typically spend around 25 minutes in face-to-face interaction with the patient.

Four Important Acupuncture CPT Codes for 2024

CPT Code 97010 is defined as “Any physical agent applied to produce therapeutic changes to biologic tissue; includes but not limited to thermal, acoustic, light, mechanical, or electric energy. The application of a modality that does not require direct (one-on-one) patient contact by the provider. Application of a modality to one or more areas; hot or cold packs.

CPT code for acupuncture 97010 is often misused and over-billed. The most common reason is that it’s difficult to establish and prove medical necessity for this service. The documentation doesn’t include an appropriate rationale for using this code. Here’s what the American Chiropractic Association (ACA) has to say about code 97010:

“It is the position of the American Chiropractic Association that the work of hot/cold packs as described by CPT code 97010 is not included in the CMT codes 98940-43 in instances when moist heat or cryotherapy is medically necessary in order to achieve a specific physiological effect that is thought to be beneficial to the patient. Indications for the application of moist heat include, but are not limited to, relaxation of muscle spasticity, induction of local analgesia and general sedation, promotion of vasodilation, and increase in lymph flow to the area. Indications for the application of cryotherapy include, but are not limited to, relaxation of muscle spasticity, induction of local analgesia and general sedation, promotion of vasodilation, and increase of lymph flow to the area.”

Medicare considers CPT Code 97010 (hot/cold packs) a “bundled” service. When a service is bundled, it means that the reimbursement for the code is built into or grouped with the reimbursement for another code. It means hot/cold pack services described by the 97010 CPT code are not separately billable when rendered to a Medicare patient. So 97010 will be a part of the primary service rendered to the patient, and in chiropractic, that will be a CMT code (98940-98942).

While some insurance payers operating as secondary to Medicare will cover 97010 when delivered in a chiropractic setting as a separate item. Do remember to include supportive documentation for hot or cold pack therapy CPT Code 97010.

• The area(s) treated
• The type of hot or cold application

Acupuncture Procedure Codes for Billing Medicare

The Centers for Medicare and Medicaid Services (CMS) announced on January 21st, 2020 that it will cover acupuncture services for chronic low back pain (ICD-10-CM code M54.5). This coverage specifically applies to localized pain in the lower back that persists for more than three months. While this decision represented a milestone, it’s important to note that certain requirements must be followed to qualify for reimbursement of acupuncture services under Medicare. To ensure compliance and eligibility, it is crucial to adhere to the frequency limitations to avoid denials:

• Patients can receive up to 12 covered acupuncture sessions within a 90-day period.
• If patients demonstrate improvement, Medicare will cover an additional eight sessions.
• Remember not to exceed the annual cap of 20 treatments.

Medicare covers the following acupuncture procedure codes:

• 97810 – Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes
• 97811 – Acupuncture, one or more needles, without electrical stimulation, each additional 15 minutes. With re-insertion
• 97813 – Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes
• 97814 – Acupuncture, one or more needles, with electrical stimulation, each additional 15 minutes. With re-insertion

Acupuncture CPT Codes for Physical Therapy-Based Treatments and Modalities

Acupuncture practices employ a diverse range of treatments and modalities to provide optimal care and support to their patients. These therapeutic interventions aim to strengthen, relax, and facilitate the healing process of muscles. The following acupuncture medical billing codes could be used for physical therapy-based treatments:

• 20550 & 20551 Tendon Injection
• 20552 & 20553 Muscle Injection(s)
• 97010 Heat Therapy
• 97016 Cupping
• 97026 Infrared
• 97112 Neuromuscular Reeducation
• 97110 Therapeutic Exercise
• 97140 Manual Therapy
• 97124 Massage Therapy
• 97530 Kinetic Activities

As per Centers for Medicare and Medicaid Services (CMS) guidelines for insurance billing for acupuncturists, the maximum acupuncture service units allowed per date of service are outlined below, in accordance with CMS Medicaid NCCI (National Correct Coding Initiative) Medically Unlikely Edits (MUE) values.

Acupuncture ICD-10 Codes

Currently, the total number of codes in the ICD-10 list is 73,639. Among these codes, the most commonly used acupuncture diagnosis codes used by clinics for reimbursement is related to lower back pain.

For billing in small practices, familiarize yourself with these essential acupuncture insurance codes:

• 97810: Manual acupuncture, initial 15 minutes.
• 97811: Manual acupuncture, each additional 15 minutes.
• 97813: Electroacupuncture, initial 15 minutes.
• 97814: Electroacupuncture, each additional 15 minutes.

When treating chronic pain with acupuncture, utilize the following codes:

• G89.0 Central pain syndrome
• G89.11 Acute pain due to trauma
• G89.12 Acute post-thoracotomy pain
• R52 Other acute pain
• G89.21 Chronic pain due to trauma
• G89.28 Other chronic post-operative pain

Acupuncture also effectively addresses muscle pain, utilizing these codes:

• M79.6 Myalgia
• M79.7 Fibromyalgia
• M62.40 Muscle spasm
• M60.9 Myositis

For persistent conditions like sciatica, consider these ICD-10 codes:

• M53.0 Cervicocranial syndrome
• M53.82 Other specified dorsopathies
• M54.2 Neck pain
• M54.3 Sciatica
• M54.4 Low back pain
• M54.6 Thoracic spine pain

Beyond pain relief, acupuncture treats various issues, applying acupuncture ICD-10 codes such as:

• H92.0 Ear pain
• H57.1 Eye pain
• R68.84 Jaw pain
• KOB.9 Tooth pain
• R07.0 Throat pain
• R52 Limb pain
• Rl0.9 Abdominal pain, unspecified
• K31.89 Other stomach and duodenal diseases
• K31.9 Stomach and duodenal diseases, unspecified

Best Practices For Insurance Billing

Accurate documentation and proper coding are crucial for successful insurance billing in acupuncture practice. Here are some best practices to consider:

1. Stay updated: Regularly review updates from the AMA and insurance carriers to ensure compliance with the latest coding guidelines.
2. Thorough documentation: Maintain detailed records of each patient encounter, documenting the treatment provided, duration, and any additional services performed.
3. Code selection: Select the most appropriate CPT codes for acupuncture based on the services rendered and document the medical necessity of the treatment. Insurance billing for acupuncturists involves using the right set of diagnosis and procedure codes during the visit.
4. Clear communication: Establish open lines of communication with insurance carriers to understand their specific requirements and guidelines.
5. Reimbursement verification: Regularly review insurance reimbursement to ensure accurate payments and address any discrepancies promptly.
6. Use Acupuncture Insurance Billing Software or Insurance Billing Service: Acupuncture billing software can help you simplify and automate the billing and coding process. The software is equipped with up-to-date coding databases and regulatory guidelines, ensuring proper code selection for different treatments and services. You can efficiently manage patient records and treatment notes and automate the claim submission and tracking process. Alternatively, you can consider outsourcing your acupuncture insurance billing services to a specialized billing partner. zHealth offers acupuncture billing services and has experienced billing professionals who handle the intricacies of insurance claims, coding, and reimbursement on your behalf.

Conclusion

Understanding and correctly utilizing acupuncture CPT codes for insurance billing is essential for the financial success of acupuncture practitioners. By staying informed about the updated codes and implementing best practices in documentation and coding, acupuncturists can optimize reimbursement and provide valuable services to their patients. Remember to consult with experts in acupuncture insurance billing services to ensure compliance and maximize financial viability in this evolving landscape. Together, let’s continue to integrate acupuncture into mainstream healthcare and enhance patient access to holistic healing.