Billing accurately and effectively is vital for the financial health of your acupuncture practice. CPT Code 97811 is important as it allows acupuncturists to bill for additional units of manual acupuncture services provided during the same session. This blog will help understand when and how to use CPT 97811, associated modifiers, and actionable tips to streamline billing processes while ensuring compliance and maximizing reimbursement opportunities.
What is the CPT Code 97811?
97811 CPT code applies to subsequent units of manual acupuncture services performed after the initial session billed under CPT 97810. Each unit represents an additional 15 minutes of hands-on treatment, including needle insertion, stimulation, and adjustments as necessary. Proper use of this code can significantly enhance revenue by capturing the full scope of services provided in a single visit.
Time Requirement: A minimum of 15 minutes of face-to-face interaction with the patient for each additional unit.
97811 CPT code description according to AAPC
The Current Procedural Terminology (CPT®) code 97811 is used for each additional 15 minutes of manual treatment, after an initial treatment, and includes re–insertion of needles. This therapeutic intervention provides relief or prevention of pain, treatment of post–operative and chemotherapy nausea and vomiting, stroke rehabilitation, and treatment of asthma, addiction, and various other health conditions.
97811 Billing Codes – When to Use It
97811 acupuncture CPT code is specifically designed for billing additional acupuncture services provided during the same patient visit. It applies under the following circumstances:
1. After Billing CPT 97810 for the Initial Session
CPT 97811 is only used once the initial acupuncture service, which involves needle insertion and manual stimulation for the first 15 minutes, has been billed using CPT 97810.
2. For Treating New or Existing Complaints
When further treatment is needed to address the same issue or new areas of concern that emerge during the visit. This ensures continuity of care within a session.
3. For Needle Reinsertion or Continued Stimulation
If the acupuncturist determines the need for reinsertion of needles or additional manual stimulation to achieve therapeutic outcomes, CPT 97811 is appropriate.
4. When Medical Necessity is Evident
CPT 97811 should only be billed when there is clear documentation that additional time and services are necessary for the patient’s condition, ensuring compliance with insurance requirements.
Importance of Understanding the Code for Effective Billing
Understanding the 98943 CPT code definition is essential for any chiropractor who wants to ensure accurate billing. When properly applied, this code reflects the full extent of care provided, leading to accurate reimbursements from insurers. Failing to use this code, or using it incorrectly, can lead to underbilling or claim denials, both of which negatively impact practice revenue.
Please note that Medicare does not cover chiropractic treatment to extraspinal regions (98943) which includes the head, upper and lower extremities, rib cage and abdomen.
Modifiers for CPT Code 97811
Modifier 25:
Use modifier 25 when acupuncture is performed on the same day as another significant evaluation and management (E/M) service. This modifier indicates that the acupuncture service is distinct and separately identifiable from the E/M service.
- Example: If a patient receives both a standard office visit (e.g., CPT 99213) and acupuncture treatment (CPT 97810/97811) during the same session, apply Modifier 25 to the E/M code to ensure both services are reimbursed.
Modifier 59:
CPT Modifier 59 is used to signify that the acupuncture service (CPT 97811) is distinct or independent from other non-E/M services provided during the same visit. It’s helpful when multiple procedures are performed, and you need to show they are not part of the same treatment session.
- Example: If acupuncture is performed in conjunction with a manual therapy session or another non-E/M procedure, Modifier 59 should be used to indicate the acupuncture is a separate service.
Modifier GP:
Modifier GP is used when acupuncture is a part of a physical therapy treatment plan, typically under the direction of a physical therapist. It helps clarify that acupuncture is being used as a rehabilitative modality within the broader context of physical therapy.
- Example: When acupuncture is integrated into a treatment plan for musculoskeletal rehabilitation, Modifier GP indicates its inclusion as part of the physical therapy regimen.
Tips for Effective Use of 97811 Acupuncture CPT Code
Accurately billing and documenting services is critical to ensuring 97811 CPT code reimbursement for your acupuncture treatments. Here are some detailed strategies to effectively use 97811 billing code, ensuring that you stay compliant with payer requirements while maximizing reimbursement.
Accurate Time Tracking
Accurate time tracking is essential for proper billing and avoiding denials. Since CPT 97811 is based on time increments, it’s crucial to document exactly how long you spend on each additional 15-minute session.
- Document Time for Each Unit:Each time you provide additional manual acupuncture, it must be documented as 15-minute increments. For example, if a patient receives 30 minutes of treatment after the initial 15 minutes (CPT 97810), bill for one unit of 97811.
- Review Documentation Thoroughly:Always verify that your notes clearly reflect the exact time spent on each segment of care. Missing or unclear time documentation is one of the reasons for claims denials or delayed payments.
Verify Payer Policies
Not all insurance providers reimburse for acupuncture services, and those that do may have different coverage rules. To ensure proper reimbursement, it’s essential to confirm the specific guidelines for each payer.
- Confirm Insurance Coverage:Before providing acupuncture services, always verify with insurance companies whether acupuncture is covered under the patient’s plan. Some insurers may require prior authorization, while others may have restrictions on how many units of acupuncture they will reimburse per visit.
- Understand Payer-Specific Billing Rules:Each payer might have slightly different rules about billing and the use of CPT codes for acupuncture services. Some insurers might require you to use specific modifiers or may have different definitions of medical necessity.
- Check for Frequency Limitations:Certain plans may limit the number of treatments covered within a specific period. Knowing these limits beforehand can help avoid denials for services beyond the allowed number of sessions.
Use Clear Documentation
Detailed and thorough documentation is the cornerstone of successful billing. For CPT 97811, it’s essential to clearly document why additional acupuncture was necessary and what areas of the body were treated.
- State the Medical Necessity:Make sure to document why additional treatment was necessary beyond the initial acupuncture service. For example, if the patient’s condition worsened or if new areas of the body required attention, note this in the medical record. This helps demonstrate the medical necessity of the extra units of service.
- Document the Areas Treated:Be specific about which body areas were treated during the additional acupuncture. This adds credibility to the claim and shows that multiple areas required treatment, justifying the use of additional units.
- Mention Needle Reinsertions:If needles were reinserted during the same session, be sure to note the reasons for reinsertion. This could include adjusting the treatment due to patient feedback or addressing areas of the body where the initial treatment didn’t provide full relief.
- Include Patient Progress and Complications:Highlight any changes in the patient’s condition, the progress made, or any complications that arose. This will help demonstrate that the service was necessary to manage the patient’s health condition. Clear documentation also supports the claim in case of an audit.
Limit Misuse of CPT 97811
To ensure compliance and avoid denials, avoid misusing CPT 97811 by adhering to strict billing practices.
- Always Bill CPT 97810 First:CPT 97811 should never be billed without first billing CPT 97810 in the same session. CPT 97811 is a supplementary code, used after the initial acupuncture service (CPT 97810), to reflect additional units of time. Failure to follow this sequence can lead to claim denials.
- Ensure Services are Distinct and Medically Necessary:Only use CPT 97811 when you’ve provided additional manual acupuncture services that are clearly distinct from the initial treatment. The services should also be medically necessary. If additional time was not spent on manual acupuncture or if the treatment was not needed, you should not bill for it.
- Avoid Unnecessary Use of 97811:Don’t inflate your services by billing for additional units unless there is a legitimate clinical need. Billing for unnecessary services is considered fraud and can result in audits, fines, and loss of insurance contracts.
- Consult with Billing Specialists:If you’re unsure about the appropriateness of billing for 97811, consider consulting with a professional billing specialist. They can ensure that you’re following proper coding practices and help navigate complex insurance policies.
Common Challenges with CPT 97811 and How to Address Them
1. Denied Claims
Cause: Claims can be denied due to improper modifier use, incorrect sequencing, or insufficient documentation.
- Modifiers: Ensure you’re using the correct modifiers like -25 or -59 for multiple services during the same visit.
- Sequencing: Always bill CPT 97810 first, followed by 97811 for additional 15-minute increments.
Solution: Review your documentation for accuracy and resubmit with corrected codes or modifiers.
2. Audits
Cause: Auditors may request documentation to verify services were delivered as described.
- Record Keeping: Keep detailed session notes that show the areas treated, time spent, and medical necessity for extra time.
Solution: Maintain accurate time logs and session notes to justify CPT 97811 use and pass audits without issues.
3. Non-Coverage
Cause: Some insurance plans may not cover acupuncture. In 2020, the Centers for Medicare & Medicaid Services decided to include acupuncture services in Part B benefits when provided by certain practitioners like physicians, nurse practitioners, and physician assistants who have a master’s or doctoral-level degree in acupuncture or Oriental medicine.
Solution: Offer cash-based payments or educate patients about membership plans to cover costs.
Conclusion
Effectively utilizing CPT Code 97811 for acupuncture services can significantly boost your practice’s revenue and ensure compliance with payer requirements. By following the strategies outlined in this guide—accurate time tracking, using correct modifiers, understanding payer policies, and maintaining thorough documentation—you can minimize billing errors, reduce claim denials, and optimize reimbursement opportunities.
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