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Insurance Billing Basics for Acupuncture

If you’ve never billed insurance before, or simply need a refresher, this primer on insurance billing will start you off on the right foot.

First and foremost, acupuncturists have to bill separately for each procedure that they do. In a cash practice, it’s common to bill one set amount per treatment, regardless what that treatment consisted of. When billing insurance, however, every procedure must be billed distinctly. Acubiller’s custom superbill and suggested pricing helps guide providers in this.

Diagnosis Codes

While you probably treat patients for a wide variety of conditions, insurance will typically only cover certain ailments – usually pain. Neck and low back pain are the most commonly covered diagnoses. If your patient suffers from those, by all means, bill with those diagnosis codes. Diagnoses such as depression, infertility, and insomnia are rarely covered, however.

If you have a specific diagnosis code that you’d like to use, include it with your benefit check request. Sometimes – not always – insurance carriers will tell us exactly what they cover. If we have a specific code, we can usually determine whether it’s covered. Note that we need the numeric ICD-10 code in order to do so.

Remember: It’s not necessarily better to have many diagnoses; one good Dx is all you need.

Procedure Codes

When acupuncture is covered, we want to bill for it, so bill for every unit of acupuncture. Acupuncture is billed in 15 minute units, and that it’s divided into acupuncture with and without electrical stimulation. You can only bill an additional unit of either if you’ve billed the first unit.

Acceptable groupings

  • 97810, 97811
  • 97813, 97814
  • 97810, 97814
  • 97813, 97811, 97814

Unacceptable groupings

  • 97813, 97810

Acupuncturists should bill for all services performed. Modalities such as moxa, cupping, and manual therapy may not be covered, but you can give it a shot.

Office Visits

Office visits are first divided into two categories: new patient and established patient. Bill a new patient office visit on their very first visit, or the first time you’ve seen the patient in three years or more.

Some evaluation is considered implicit as part of the acupuncture procedure, but acupuncturists can still bill for an office visit for established patients. Acubiller suggests billing an established patient office visit after 5-6 visits when you need to assess progress, or when the patient presents a new diagnosis. Billing more often than this may cause your claims to be red-flagged.

Office visit codes are also divided by the severity of the patient’s condition and the amount of time and effort demanded.

  • 99202/99212: About 20 minutes; medical decision making that is straightforward; none to minimal amount and/or complexity of data to be reviewed; no to minimal risk of significant complications or morbidity/mortality.
  • 99203/99213: About 30 minutes; medical decision making that is of low complexity; limited amount and/or complexity of data to be reviewed; low risk of significant complications or morbidity/mortality.
  • 99204/99214: About 45 minutes; medical decision making that is of moderate complexity; moderate amount and/or complexity of data to be reviewed; moderate to significant risk of significant complications or morbidity/mortality.
  • 99205/99215: About 60 minutes; extended history of present illness; complete review of symptoms; complete past, family and/or social history; comprehensive examination; extensive number of diagnoses or management options; medical decision making that is of high complexity; extensive amount and/or complexity of data to be reviewed; high risk of significant complications or morbidity/mortality.

Billing No-Nos

1) Billing an office visit every time you see a patient, or overusing codes 99205/99215, can get you red-flagged.

2) Billing for your immediate family is another way to get red-flagged, and we don’t recommend it.

3) If it’s legal in your state, you can offer a time of service discount to your cash patients (i.e. charge them less than what you would bill insurance). However, we recommend that that be no more than a 20% discount off your insurance price. So if you bill insurance $200, your cash price shouldn’t be lower than $160. Check with your state association to see if a time of service discount is legal in your state, and your contract if you’re in network.