If you are an acupuncturist, you are already familiar with the code 97810. The CPT-4 procedure code 97810 is a general acupuncture treatment code. This includes 15 minutes of verified time with the patient while performing the treatment. Verified time means that the time increments are documented in the patient’s record for the correct date of service. 97811 is used for every additional 15 minutes spent administering treatment. This does not include the time the patient spends inactive on the table. For example, if a frontal treatment is performed without any other services, 97810 should be billed. However, if the patient receives frontal and posterior treatment, 97810 and 97811 should be used.
Now that we have explained what the procedure codes 97810 and 97811 mean, we can start discussing the top 2 reasons why you are not funded by insurance companies.
Claim submitted to Medicare or Medicaid
Neither Medicare nor Medicaid will reimburse acupuncture claims. Medicare and Medicaid are excellent insurance programs for the young, poor, sick, and elderly; however, insurance plans do not cover everything. Medicare determines medical necessity when it receives the claim. However, Medicare does not consider acupuncture, holistic medicine, alternative therapies, and homeopathy to be medically necessary procedures. Therefore, acupuncture claims will not be paid. If your Medicare or Medicaid insurance plan does not cover acupuncture, you will be responsible for paying the entire bill if you receive these services. Many acupuncturists are willing to discount their prices for patients who do not have insurance.
Medicare also offers supplemental plans, allowing someone to get coverage where there wasn’t before. Medicare Advantage plans may offer acupuncture and alternative therapies. Although Medicare Advantage plans cover acupuncture, the service will only be paid for if it is determined to be medically necessary and the services are performed by a licensed health care professional who participates in Medicare. To find out if your Medicare patients have acupuncture insurance, take the Benefits Check. An experienced and competent medical biller must know whether or not a claim will be paid before it is passed on to the insurance company. A thorough and documented benefit verification will give you the information you need to make that determination, each and every time.
Incorrect procedure code
There are four codes that are widely used by acupuncturists. We have already discussed two of those codes, 97810 and 97811. However, there are two additional codes, which are 97813 and 97814. 97813 is used when the acupuncturist uses electrical stimulation on one or more needles. Remember, this is only for the initial 15 minutes spent doing the procedure. 97814 is used for each additional 15 minutes spent using electrical stimulation on one or more needles. Often licensed acupuncturists simply code procedures incorrectly. That is why keeping good records is imperative for the acupuncturist. For example, if a provider performs general acupuncture and then performs electrical stimulation acupuncture, how would you bill for that visit? Many providers believe that the correct way to encode this visit is 97810 and 97813. However, 97810 and 97813 are used for the first 15 minutes. Therefore, it must be determined which procedure was performed first. Since the general acupuncture was performed first, we will bill 97,810 for the first procedure and 97,814 for an additional 15 minutes of acupuncture with electrical stimulation. This is the correct way to bill this scenario.
Acupuncture insurance billing can be complicated for many medical billing services and in-house staff. Physicians can have more than 50% of their claims denied simply because they haven’t learned how to properly code procedures. However, with extensive research on acupuncture coding and how to use it correctly, experienced medical billing services can help you expect consistent reimbursement from insurance companies.