On Pins and Needles: Pain Management Looks at Acupuncture

Summary: 

Medicare now allows payment for acupuncture, as well as dry needling. The difference between these two treatment techniques may be confusing to some pain practitioners. Today's article will address these differences and the requirements for billing.

We can all learn something from each other. Eastern healing and Western medicine—the key is finding what works. This naturally involves a willingness on the part of practitioners in both traditions to consider the science behind techniques they may initially find unconventional. Some are actually putting this common-sense approach into practice. Take, for example, Medicare and acupuncture. What was once taboo to the federal payer is now accepted and actually compensated when performed in connection with certain patient conditions.

In instructions to its Medicare administrative contractors (MACs), CMS has directed that, as of January 21, 2020, acupuncture may be reimbursed under certain conditions. Recent revisions in late August to the Medicare Claims Processing Manual (MCPM) have reinforced that stance. So, for our chronic pain groups or anesthesia groups with a chronic pain component, this may be a good time to take a brief look at acupuncture and similar services that might be employed in the management of patient pain.

Differentiating the Modalities

It may be helpful to point out that there are different codes, techniques and requirements when it comes to sticking a needle into a patient's skin and/or muscle. To draw contrast and ease confusion, we will now look at the differences in these somewhat similar modalities. This exercise may help you to determine what procedure you're actually performing, at least in the eyes of the AMA and the payer. 

1. Trigger Point Injection (TPI)

First, there are trigger point injections, which have been around for decades as a billable option for pain practitioners. To get paid for a traditional trigger point injection, you have to actually have an injectate. In other words, a therapeutic agent must pass through the needle into the patient's body. Here are the CPT codes for TPI:

• 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 

• 20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s)

No pain provider is going to confuse TPIs with acupuncture. However, the next example may be a bit confusing to providers as it has great commonality with both TPI and acupuncture.

2. Dry Needling (DN)

Some pain physicians have incorporated this procedure into their practice for a few years now. It essentially involves sticking a needle into a muscle (often a trigger point), but without an injectate. While this sounds suspiciously like a description of acupuncture, dry needling and acupuncture involve 2 different code sets. Here are the codes for DN:

​• 20560 Needle insertion(s) without injection(s), 1-2 muscles 

• 20561 3 or more muscles

Notice that the DN codes make no mention of trigger points as the TPI code descriptors do, though by most clinical accounts trigger points are typically the target of the dry needling. Now, let's see how DN differs from acupuncture.

3. Acupuncture

Let's begin by looking at the acupuncture code set:

• 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 of needle(s) 

• 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 of needle(s)

The first difference that we notice between DN and acupuncture is that, unlike the DN and TPI codes, the acupuncture code descriptors make no mention of "muscle(s)." Nevertheless, it's clear from the medical literature that acupuncture may go beyond the epidermal layer into the musculature. According to one expert in both DN and acupuncture, both techniques use the same type of needle. So, what's the real difference in these two modalities?

According to Medical News Today,

Practitioners of dry needling attempt to release tension from knots and pressure points in muscles. Acupuncturists insert needles to release endorphins and affect the nervous system. Traditionally, acupuncture was used to align a person's energy, or chi.

One university health system had this to say about the difference between the two pain therapies:

However, the primary difference between acupuncture and dry needling is that acupuncture treats for the purpose of altering the flow of Qi (or energy) along traditional Chinese meridians while dry needling follows evidence-based guidelines, recommended "point" locations, and dosages for the treatment of specific conditions.

It would appear from a wide range of literature that while both modalities are ultimately employed for the alleviation of pain, the primary difference between DN and acupuncture is in the practitioner's philosophical or medical starting point and initial intent, i.e., to relieve tension and increase range of motion or release healing energy.

The Deeper Points

Now that we have noted a few differences between DN and acupuncture, let's take a deeper dive into what is required to bill the acupuncture codes to Medicare. Let's begin with another look at the code set. 

• Notice, first, that unlike the TPI and DN code sets, acupuncture services involve time-based codes. For example, in order to bill 97810 or 97813, the requirement is 15 minutes. According to CMS, this time involves personal attendance with the patient—not the total time the needles remain in place.

• Second, consider also that you must meet the AMA minimum threshold for time-based coding, i.e., you would need to provide the service for more than half of the 15-minute time period. In other words, to bill the initial code, you would need to provide the service for at least eight minutes. 

• Third, the CPT manual contains a parenthetical note that when performing both acupuncture and dry needling during the same session, you may not bill the DN codes; rather, you are to "report only the time-based acupuncture codes." 

• Fourth, the codes are divided between electrical and non-electrical stimulation. 

• Fifth, the add-on codes, 97811 and 97814, contain the additional condition, "with re-insertion of needles." According to AAPC Tips, "use of these add–on codes requires re–insertion of the needle or needles. [Emphasis added.]

Significantly, the CMS transmittals in January and August both emphasized that acupuncture may only be billed for the treatment of chronic lower back pain (cLBP). Therefore, an acupuncture claim cannot be submitted to Medicare for the treatment of other conditions, such as fibromyalgia and osteoarthritis.

Pain providers should also be aware of the limits of treatments allowed by Medicare. According to National Coverage Determination (NCD) 30.3.3, as it pertains to claims for acupuncture:

Effective for claims with DOS on and after January 21, 2020. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances: For the purpose of this decision, cLBP is defined as: 

• Lasting 12 weeks or longer 

• Nonspecific, in that it has no identifiable systemic cause (for example: not associated with metastatic, inflammatory, infectious, etc. disease) 

• Not associated with surgery 

• Not associated with pregnancy An additional 8 sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.

An additional 8 sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.

Finally, since we have discussed both acupuncture and dry needling, it is important to note that the above-referenced NCD appears to combine both modalities under the same umbrella, and specifically as to diagnosis, stating: "All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare." Be advised that, while Medicare covers both acupuncture and DN, some commercial carriers will only pay for acupuncture.

Last Word

For providers wishing to pursue these techniques, you will want to make sure your documentation reflects the procedure (e.g., dry needling or acupuncture), the diagnosis (e.g., chronic lower back pain not due to 

__________), the time involved in personal presence with the patient, inserting and manipulating the acupuncture needles, any reinsertions, and whether or not electrical stimulation was used. As far as payment, the Medicare physician fee schedule (MPFS) breaks down acupuncture services as follows (national average):

• 97810 (Facility) - $31.76 (Non-facility) - $37.89 

• 97811 (Facility) - $26.71 (Non-facility) - $28.87 

• 97813 (Facility) - $34.29 (Non-facility) - $42.22 

• 97814 (Facility) - $29.23 (Non-facility) - $34.65

For those commercial plans that cover acupuncture, providers can expect somewhat higher reimbursement than the above Medicare rates.

If you have further questions about this topic, please contact your account executive or reach out to us at info@anesthesiallc.com.