Billing for Office Visits, Needles and Other Services
Can an Acupuncturist bill for an "office visit" on all visits in addition to the acupuncture codes?
No, you may not bill for an "office visit" or more correctly, an evaluation and management service (E&M codes 99211-99215), on each visit. Your acupuncture code and services 97810, 97811, 97813 and 97814 include pre-service, intra-service and post-service evaluation and management for the typical follow factors of history, evaluation, management and chart documentation done as part of the overall daily treatment. This is why initial examination and follow-up examinations (about 4 weeks) require modifier -25 to indicate that the evaluation done on the particular visit is above and beyond the one associated with the acupuncture service.
If I do one unit of manual acupuncture and one unit of electroacupuncture on a visit, may I bill 97810 for the manual and 97813 for the electrical?
No, both 97810 and 97813 are for the initial set of needles. And there is only one initial set per visit. Each set of needles after the first is billed as a subsequent set. Therefore, if the initial were manual, 97810 would be billed for the first set. The second set would be billed with 97814 to indicate the second set was electrical. Either 97810 or 97813 is used as the initial code, with any subsequent sets billed with 97811 or 97814.
Is it reasonable to bill for the needles used in a treatment session as a separate line item for acupuncture services?
No, needles are inherent to the acupuncture service and are not separately billed from the acupuncture code.
Are there a maximum number of units that are allowed per visit for acupuncture?
Yes, 97810 and 97813 can only be billed 1 unit while 97811 can be billed with a maximum of 3 units and 97814 maximum 2 units.
There is an aspect of reasonable and necessary that might trigger an audit of your notes. It is not unusual and in fact typical for an acupuncture visit to have multiple sets of needles billed. On average, two to three sets or units are most common, though one set might certainly be all that is necessary and adequate to resolve the presented issue. Four or more sets might be considered unusual, but not inherently excessive. An acupuncture provider should be sure, if queried or audited, that the chart notes adequately demonstrate the multiple sets that were applied and the medical necessity for the amount.
If I insert only one needle on the second set, is that billable?
Yes, the codes for additional sets allow billing for that set when of one or more needles are used. The key factor for 97811 and 97814 is that at least one needle is used (reinserted). If more than one is used, it does not allow additional billing, as one or more in the same grouping would constitute a set.
It is necessary that I be a member of an insurance plan in order to start billing insurance?
No, it is not. As long as you are a licensed acupuncture provider for your state, you may bill insurance for your services. There are plans that might only pay "in network" providers, meaning you have to be a member for reimbursement in that particular plan. However, most insurance plans have benefits and payment whether a provider is in or out of network. Some plans also do not form networks and simply accept claims from providers.
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