Procedure code and Description
• 97810: Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
• 97811: Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles
• 97813: Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
• 97814: Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles
Acupuncture: A chiropractic provider may not provide acupuncture services until certified by the Florida Board of Chiropractic Medicine. Acupuncture is reported based on 15 minute increments of personal (face-to-face) contact with the patient, not the duration of acupuncture needle(s) placement. If no electrical stimulation is used during a 15 minute increment, use 97810 or 97811. If electrical stimulation of any needle is used during a 15 minute increment, use 97813 or 97814. Only one code may be reported for each 15 minute increment. Use either 97810 or 97813 for the initial 15 minute increment. Only one initial code is reported per day.
The FEP does not include benefits for acupuncture when performed by a chiropractor.
Acupunctures CPT code and fee schedules
| Insurance | CPT Code 97810 | CPT Code 97811 | CPT Code 97813 | CPT Code 97814 |
|---|---|---|---|---|
| Medicare | $37.89 | $28.87 | $42.22 | $34.65 |
| Medicaid | $35.00 | $27.50 | $40.00 | $33.00 |
| Blue Cross Blue Shield | $36.50 | $29.00 | $41.00 | $33.50 |
| UnitedHealthcare | $35.75 | $28.25 | $40.75 | $33.25 |
| Aetna | $36.00 | $28.50 | $41.00 | $33.50 |
| Humana | $35.50 | $28.00 | $40.50 | $33.00 |
| Cigna | $36.25 | $28.75 | $41.25 | $33.75 |
| Kaiser Permanente | $35.25 | $27.75 | $40.25 | $32.75 |
| UnitedHealthcare Community Plan | $35.00 | $27.50 | $40.00 | $33.00 |
Reimbursement Guidelines
This policy enforces the code description for Acupuncture services which are to be reported based on 15 minute time increments of personal face-to-face contact with the patient and not the duration of the needle(s) placement. In addition, CPT® code guidelines state only one initial CPT code, 97810 or 97813, should be reported per day.
The cost of needles (A4212 and A4215) is included in the Acupuncture service and will be denied if submitted in addition to the Acupuncture service. The CMS National Physician Fee Schedule (NPFS) indicates these supplies are part of the Practice Expense (PE) and should not be reported separately.
Consistent with the CPT code description and the CMS NCCI Procedure to Procedure Coding Edits (PTP), electrical stimulation services (97014, 97032 and G0283) should not be reported separately in addition to specific Acupuncture services that include electrical stimulation (97813, 97814 and S8930). A modifier may be appropriate when an electrical stimulation service is performed distinctly and separate from the Acupuncture service and the documentation supports the service was not related to the Acupuncture.
Per CPT guidelines an evaluation and management (E/M) service may only be reported in addition to Acupuncture services if the patient’s condition requires a significant, separately identifiable E/M service above and beyond the usual pre-service and post-service work associated with the Acupuncture service. When a separate E/M service is reported, the time spent for the E/M service is not to be included in the time UOS for the Acupuncture service
Covered Services for Medicare Advantage Members:
According to the Centers for Medicare & Medicaid Services (CMS) Internet-only manual, Publication 100-02 Medicare Benefit Policy Manual, chapter 15, section 30.5, chiropractors’ services extend only to treatment by means of manual manipulation of the spine to correct a subluxation. All other services furnished or ordered by chiropractors are not covered. Chiropractors are not limited to any specific procedures and may render services as they feel necessary, but according to CMS guidelines; the benefit will only cover manual spinal manipulation, which includes procedure codes: 98940, 98941, and 98942.
The following procedure code ranges will deny for chiropractors as non-covered services:
• 00100 through 98929
• 98943 through 99607
• A0021 through V5364
Guideline from BCBS
Acupuncture and an initial evaluation (for a new patient) is covered when rendered by a licensed doctor of acupuncture (D. Ac.) or physician (State of Rhode Island-licensed MD or DO)* only. Acupuncture assistants are not recognized for separate reimbursement and are therefore considered inclusive of the acupuncture reimbursement.
An initial evaluation (99201-99205) is allowed only for new patients. According to CPT guidelines, a new patient is one who has not received any professional services from the physician within the past three years.
The following services are not covered:
** **cupuncture with electrical stimulation;
** **djunctive therapies, such as but not limited to moxibustion, herbs, oriental massage, etc.;
** **cupuncture when used as an anesthetic during a surgical procedure;
** Precious metal needles (e.g., gold, silver, etc.);
** **cupuncture in lieu of anesthesia;
** **ny other service not specifically listed as a covered service.
*Acupuncture services may be rendered by a physician (MD or DO) when the following Rhode Island Department of Health criteria has been met:
2.2 Any physician licensed in Rhode Island under the provisions of Chapter 5-37 who seeks to practice medical acupuncture as a therapy shall comply with the following:
2.2.1 Meet the requirements for licensure as a doctor of acupuncture set forth in the Rules and Regulations for Licensing Doctors of Acupuncture and Acupuncture Assistants promulgated by the Department of Health; or 2.2.2 Successfully complete a course offered to physicians that meets the requirements set forth in these regulations and includes no less than the following:
a) a minimum of three hundred (300) hours of formal instruction;
b) a supervised clinical practicum incorporated into the formal instruction required in subsection 2.2.2(a) (above).
Acupuncture is a covered benefit for those groups who have purchased the acupuncture rider or who have an acupuncture benefit. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable acupuncture benefits/coverage. Rhode Island-mandated benefits do not apply to Plan 65, FEHBP, and Medicare Advantage plans. Selffunded groups may or may not choose to follow state mandate(s).
Acupuncture is the practice of piercing the skin with needles at specific body sites to induce anesthesia, to relieve pain, to treat various nonpainful disorders, and to alleviate withdrawal symptoms of opioid dependence. Acupuncture has also been used or proposed for a large variety of indications.
Acupuncture is a traditional form of Chinese medical treatment that has been practiced for over 2000 years. It involves piercing the skin with needles at specific body sites. The placement of needles into the skin is dictated by the location of meridians. These meridians, or channels, are thought to mark patterns of energy, called Qi (Chi), that flow through the human body. According to traditional Chinese philosophy, illness occurs when the energy flow is blocked or unbalanced, and acupuncture is a way to influence chi and restore balance. Another tenet of this philosophy is that all disorders are associated with specific points on the body, on or below the skin surface.
Several physiologic explanations of acupuncture’s mechanism of action have been proposed including an analgesic effect from release of endorphins or hormones (eg, cortisol, oxytocin), a biomechanical effect, and/or an electromagnetic effect.
There are 361 classical acupuncture points located along 14 meridians, and different points are stimulated depending on the condition treated. In addition to traditional Chinese acupuncture, there are a number of modern styles of acupuncture, including Korean and Japanese acupuncture. Modern acupuncture techniques can involve stimulation of additional non-meridian acupuncture points. Acupuncture is sometimes used along with manual pressure, heat (moxibustion), or electrical stimulation (electroacupuncture). Acupuncture treatment can vary by style and by practitioner, and is generally personalized to the patient. Thus, patients with the same condition may receive stimulation of different acupuncture points.
Scientific study of acupuncture is challenging due to the multifactorial nature of the intervention, variability in practice, and individualization of treatment. There has been much discussion in the literature on the ideal control condition for studying acupuncture. Ideally, the control condition should be able to help distinguish between specific effects of the treatment and nonspecific placebo effects related to factors such as patient expectations and beliefs and the patient-provider therapeutic relationships. A complicating factor in selection of a control treatment is that it is not clear whether all 4 components (ie, the acupuncture needles, the target location defined by traditional Chinese medicine, the depth of insertion, and the stimulation of the inserted needle) are necessary for efficacy.
CODING Commercial Products
Local providers in the Acupuncture Specialty (053) are able to file only the codes found in this policy.
Providers should not file an E & M service on the same date of service as the acupuncture service unless it meets the definition for use of Modifier -25. The acupuncture codes and services 97810, 97811 include preservice, intra-service and post-service evaluation and management for the typical following factors of history, evaluation, management and chart documentation done as part of the overall daily treatment.
The following CPT codes are covered under the acupuncture rider only:
97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-onone contact with the patient
97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)
Evaluation and Management codes are only used for separately identifiable procedures.
99201 Office or other outpatient visit for the evaluation and management of a new patient
99202 Office or other outpatient visit for the evaluation and management of a new patient
99203 Office or other outpatient visit for the evaluation and management of a new patient
99204 Office or other outpatient visit for the evaluation and management of a new patient
99205 Office or other outpatient visit for the evaluation and management of a new patient
99211 Office or other outpatient visit for the evaluation and management of an established patient
99212 Office or other outpatient visit for the evaluation and management of an established patient
99213 Office or other outpatient visit for the evaluation and management of an established patient
99214 Office or other outpatient visit for the evaluation and management of an established patient
99215 Office or other outpatient visit for the evaluation and management of an established patient
The following CPT codes are contract exclusions (non-covered):
97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s).
What is the Medicare 2020 fee schedule for Acupuncture?
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