Personal injury protection (PIP) claims are a hassle; but if you jump through the hoops correctly, they tend to pay well. For a licensed acupuncturist, motor vehicle accidents (MVA) and workers’ compensation (WC) claims are the most common types of PIP claims.
1. Collect information before treating
Data collection is the first step in billing for PIP claims. For everything to go smoothly, collect the following information before treating the patient:
- Basic patient data (full name, DOB, full address, sex)
- The patient’s insurance carrier
- The patient’s claim number
- The claims adjuster’s name and phone number (including extension)
- The date of injury
When collecting patient data, repeat it back to the patient to confirm. Take extra care with the spelling of names and street addresses.
2. Contact the Claims Adjuster
Before treating the patient, contact the claims adjuster. Here’s a short list of questions to ask:
- Is the injury claim open?
- Will acupuncture claims be considered? (see #5 below)
- What is the date of injury?
- What is the mailing address and/or fax number for claims? (Insurance companies may have multiple PO boxes and fax numbers, so always ask.)
- Are there any documentation, referral, or pre-authorization requirements?
3. Document properly
No documentation, no payment! Prepare your SOAP notes carefully. Include procedure codes, chart progress, diagnoses, and a summary. When you’re billing time-based procedure codes, document the start and end times for each unit. Be meticulous — it matters!
Acubiller clients: We charge minimal fees to cover mail/print costs. Refer to our Fee Schedule for more information.
4. File correctly
- Indicate the date of injury, PIP type (MVA or WC), and claim number (as the member ID). Log these data in the patient’s record at your clearinghouse.
- Include documentation. The patient’s first claim should generally be sent with a correctly-filled W9 and, when relevant, a copy of the referral or authorization. Every claim should be sent with SOAP notes.
- Follow the carrier’s billing guidelines. Observe any diagnosis restrictions. Stay within the scope of your license.
5. Bill companies that will pay
If an insurance company won’t even consider acupuncture claims, don’t bother (unless you’re billing for a denial EOB). Seems like a no-brainer, right? Calling the claims adjuster before rendering treatment is the best way to distinguish between insurance vs cash patients.
6. Code with care
PIP claims may challenge you with unfamiliar diagnoses. Generally speaking, diagnosis codes for sprains and strains require extra attention. Some sprain and strain diagnoses have three versions:
- Initial (suffix A). Indicates treatment rendered prior to recovery: “based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time”. Examples: S76.019A, S29.019A, S96.811A
- Subsequent (suffix D). Indicates recovery. “encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following injury treatment.” Examples: S76.019D, S29.019D, S96.811D
- Sequela (suffix S). Indicates the late effects of an injury: “for use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn.” Examples: S76.019S, S29.019S, S96.811S
For more information, see the AAPC’s Initial, Subsequent, or Sequela Encounter?