CMS Covers Acupuncture When Case Meets These Requirements

Your patients with chronic back pain will be thrilled to know that CMS now offers reimbursement for acupuncture services. But to unlock pay, you must follow several coverage rules or else you’ll be stuck having to write off the service or collect the pay from the patient.

Select 987810-987814 Based on Type and Duration

Look at two factors to choose from the four CPT acupuncture 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

Choose the first set for acupuncture without electrical stimulation and the latter set for acupuncture with electrical stimulation.

Codes 97810-97814 are are time-based codes. Apply CPT’s time rules that allow counting time when documentation shows the mid-point had been reached.

To use the re-insertion codes, either additional acupuncture needles must be added after the first 15 minutes or acupuncture lifting techniques must be used.

Follow ICD-10-CM, Frequency Restrictions

Medicare covers acupuncture (CPT codes 97810-97814) for people with chronic low back pain (M54.5, Low back pain), effective January 21, 2020. You will get a denial if your treatment exceeds the frquency limitations:

Your patients can have up to 12 covered sessions in 90 days.
Medicare will also cover an additional eight sessions for patients who demonstrate improvement.
Do not exceed the annual cap of 20 treatments.

Document Pain Length and Associated Conditions

To support medical necessity, make sure documentation shows that the chronic lower back pain lasted 12 weeks or longer, had no identifiable systemic cause and is not associated with surgery or pregnancy. Discontinue treatment if the patient is not improving.

Source: Read the new CMS decision memo policy.

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