By Peter R. Martin
The provision of acupuncture and oriental medicine within the third-party payer system of American healthcare necessitates the use of codes which designate what is being treated and what procedures are being utilized. The codes used that designate diagnoses are listed in the International classification of Disease, 9th Revision, commonly referred to as the ICD-9. Some state rules and regulations restrict licensed acupuncturists from diagnosis in medical terms. Still, the ICD-9 contains many codes that are sign and symptom oriented and well within those limits. If you have a referral with a diagnosis and treatment plan from the primary care physician, so much the better. But you must provide an ICD code when billing and that diagnosis should be clear in you chart notes as well. The codes that designate therapeutic procedures are listed in Current Procedural Terminology (CPT), updated and published yearly by the American Medical Association.
Until 1997 there were no CPT codes for acupuncture. The advent in that year of the CPT codes for acupuncture (97780) and acupuncture with electrical stimulation (97781) was a milestone for integration. A new milestone was reached with the doubling of the acupuncture code set as of January 1, 2005 when 97780 and 97781 were retired. In their place we have:
- 97810 Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
- 97811 Acupuncture, one or more needles, without electrical stimulation, each additional 15 minute increment of personal one- to-one contact with the patient, with reinsertion. (List separately in addition to code for primary procedure)
- 97813 Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
- 97814 Acupuncture, one or more needles, with electrical stimulation, each additional 15 minute increment of personal one-on- one contact with the patient, with reinsertion. (List separately in addition to code for primary procedure)
There cannot, of course, be milestones without obstacles and the path of development for these new codes was less than smooth. One glaring example of this is found in the definition of the codes, which includes the word .reinsertion.. This is not a word that has meaning within the acupuncture community since we do not reuse needles or points within a single treatment. This word was added by the AMA Reimbursement Update Committee (see below) to connote an additional set of points that would demand a greater amount of work. A .set. is undefined but according to the code definition it could be a single point. It must, for documentation purposes, be distinctly separate in some fashion and in the process of code development it was implied that a set would require repositioning of the patient.
The CPT codes are the property of the AMA and they serve as a significant source of income for that organization. The CPT codes are used nationwide and have become not only the de facto standard but also the only HIPPA compliant code set. HIPPA, amongst many other things, mandated that there be a consistent code set across the country, no longer would there be regional codes, no longer would individual payors be able to use their own codes. The Centers for Medicare and Medicaid Services (CMS) is responsible for contracting with the AMA and establishing what is essentially a government mandated monopoly. In this process the CPT codes have come up against some criticism for being incomplete. An alternative code set, the Advanced Billing Concept (ABC) codes has been developed specifically with complementary and alternative medicine in mind. This was certainly not the focus of CPT. When HIPPA became the law of the land there existed a certain amount of pressure on the CPT to expand the code set. Acupuncture was one area ripe for expansion.
The CPT Committee formed a workgroup comprised of representatives from the professional organizations that have acupuncture in their scopes of practice. These included the American Chiropractic Association (ACA), the American Academy of Medical Acupuncture (AAMA), the American Association of Oriental Medicine (AAOM) and the Acupuncture and Oriental Medicine Alliance (AOMAlliance). This group of practitioners met for over a year to develop a rational system that allowed for greater variability in coding an acupuncture treatment and still stood up under the scrutiny of, and was understandable to, the CPT Committee, few of whom had any knowledge of acupuncture. Time-based codes are something that has many precedents in the framework of the CPT code set and the conclusion of the workgroup was that this was the best strategy for additional acupuncture codes. These codes were indeed accepted by the CPT Committee and were then sent to the Reimbursement Update Committee (RUC) for valuation.
The valuation process is one that all CPT codes go through and is, as they say, .where the rubber meets the road.. Valuation of a code means establishing a number called a Relative Value Unit (RVU) for that code. The number of .Units. expresses a .Value. which is .Relative. to that of other medical procedures, whether they be a colonoscopy or a cold pack. The RVU is made up of three separate component values. (The process of arriving at these values is beyond the scope of this article and to some extent proprietary to the AMA. Suffice it to say that it tries to be scientific, or at least systematic.) The .work value. denotes the training, effort and intensity of the practitioner.s effort. The .malpractice value. denotes the risk involved in the procedure. The .practice expense value. denotes the cost of the office and equipment needed to perform the procedure. These three values are added to arrive at the RVU for that particular code. The RVU is then multiplied by a .conversion factor. to arrive at a dollar value for each code. The conversion factor is a dollar amount that is established contractually by insurers or regionally by CMS regulations for Medicare and Medicaid services. So, RVU x Conversion Factor = Reimbursement. The Medicare conversion factor for 2007 is $37.8975, which is one reason your physician colleagues have very mixed feelings about being involved in it.
Which begs the question: What is the RVU for acupuncture? When 97780 and 97781 were established there was disagreement among the practitioners consulted and since neither code was a Medicare/Medicaid reimbursable expense CMS did not feel it necessary to publish values. There do exist other RVU systems, which are published independently of CMS and the AMA. Relative Value Studies Inc. published values of 1.83 for 97780 and 1.96 for 97781. When CMS fist published the values for 97810-97814 they ranged from .53 to .68. This was due to, through error or omission, the cost of actually having an office (the practice expense portion) being left out of the code value. Any use of those code values is a clear under- valuation of acupuncture services but you may find an insurer still using these values. Fortunately this error was corrected by CMS and you will find the RVU as of 2007 at:
- 97810 .98
- 97811 .76
- 97813 1.05
- 97814 .85
The understanding of the workgroup was that the most common level of service would be 30 minutes of patient contact time, therefore, if there is no electrical stimulation, 97810 and one unit of 97811. If there is electrical stimulation one would use 97813 or 97814 or both as appropriate. The CPT initially mandated that one cannot mix the acupuncture without electrical stimulation codes and acupuncture with electrical stimulation codes but has since changed that to reflect the clinical reality.
There are, of course, other nuances to code use. One of these is the aforementioned .reinsertion.. Another involves evaluation and management (E&M). E&M codes are divided into a new and a returning patient series of five levels of increasing complexity, time and charge. New patient codes are 99201 through 99205. Established patient codes are 99211 through 99215. The difference between a new patient and an established patient is three years. If the patient has not been seen by anyone in your clinic in that amount of time they can be considered .new.. Specific definitions of these codes can be found in the CPT manual. The 2007 E&M RVU are:
- 97201 .99
- 97202 1.73
- 97203 2.56
- 97204 3.92
- 97205 4.93
- 97211 .55
- 97212 1.02
- 97213 1.66
- 97214 2.52
- 97215 3.42
Typically within this model one patient encounter would entail the use of one E&M code and one or more procedure codes. The new codes for acupuncture do have a small amount of E&M included but it is minimal. The time element of the new codes are divided into three segments:
. .Pre-service., greeting of the patient and a brief interval history. The code is based on this being 3 min.
. .Intra-service., everything connected with doing the procedure – washing your hands, positioning the patient, locating and cleaning the points, inserting and stimulating the needles, checking on the patient, removing the needles. The code is based on this being 15 minutes. This does not include needle retention time when you are not directly monitoring or communicating with the patient.
. .Post-service., charting and any instructions to the patient. The code is based on this being three minutes.
If your pre- and post- service time substantially exceeds 6 minutes and is clinically necessary you could charge for a suitable level of E&M, but it is essential that you document that you have fulfilled the requirements of that E&M code per the CPT manual and you must modify the E&M code with a -25 modifier to denote that this is a significant, separately identifiable level of service. Insurers will expect E&M to be billed with a new patient and on reevaluation or a new diagnosis of an established patient. It is inappropriate to bill an E&M for each visit. Everything you code for must be supported by your chart notes.
Historically the profession of acupuncture has been based on a cash practice with little variation of charge from patient to patient. Moving towards integration into the reimbursement structure of American healthcare means adopting and adapting the standard practices of coding to what we do.
Our professional responsibility is to charge with consistency a reasonable amount for our services. Insurance is not a cash cow to be milked by the sophisticated practitioner but an expression of the shared risk of human suffering.