On January 21, 2020, a CMS Newsroom press-release read,

"CMS finalizes decision to cover Acupuncture for Chronic Low Back Pain for Medicare beneficiaries"

This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for patients with chronic low back pain. A review of outcomes from several studies concluded that acupuncture improves health outcomes for Medicare beneficiaries with chronic low back pain.

With all eyes on the opioid crisis, providing coverage for acupuncture, an alternative therapy, is a strategic move in the challenge to lower dependence on prescription opioids.

In the press-release from Medicare, HHS Secretary Alex Azar stated,

"President Trump has promised to protect and improve Medicare for our seniors, and deciding to cover this new treatment option is another sign of that commitment. Medicare beneficiaries will now have a new option at their disposal to help them deal with chronic low back pain, which is a common and sometimes debilitating condition."

Coverage Guidelines (National Coverage Determination 30.3)

According to the changes made to the Social Security Act 1862(a)(1)(A), the newly approved acupuncture benefit will cover up to 12 sessions over 90 days and an additional 8 sessions for those patients with chronic low back pain who demonstrate improvement. Chronic low back pain is defined by CMS as lasting 12 weeks or longer, having no systemic cause (i.e., metastatic, inflammatory, infectious, etc., disease), [and] not associated with surgery or pregnancy.

This is applicable to the following benefit categories but may not be an exhaustive list: 

• Incident to a physician's professional service (§ 1861(s)(2)(A))
• Inpatient Hospital Services (§ 1861(b))
• Outpatient Hospital Services Incident to a Physician's Service (§ 1861(s)(2)(B))
• Physicians' Services (§ 1861(s)(1))

Limitations include: 

• No more than 20 acupuncture treatments may be provided in any 12-month period
• Treatment must be discontinued if the patient is not improving or is regressing

CMS Includes Dry Needling in the Definition of Acupuncture

The National Coverage Determination (NCD) 30.3 reads, "Acupuncture is the selection and manipulation of specific acupuncture points by penetrating the skin with fine needles" and "All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare." These statements identify dry needling (20560, 20561) as an acupuncture service by Medicare that would be covered for chronic low back pain (cLBP) when all essential criteria has been met by the provider qualifications and patient documentation. 

Note: As this is a new NCD, be sure to watch for a Local Coverage Determination (LCD) and linked Article from your specific Medicare Administrative Contractor (MAC) for specific guidelines, codes, and documentation required to support coverage. Always check with individual private payors for individual coverage policies and guidelines as well. 

Who Can Perform Acupuncture Services?

There are strict guidelines as to the type of provider who can furnish acupuncture services as defined in the SS Act; 1861(r)(1) regarding physicians and 1861(aa)(5) for nonphysician practitioners and auxiliary personnel. Individual state requirements must also be met. 

Additionally noted is the requirement of:

1. A Masters or Doctoral-level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and 
2. A current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e., Puerto Rico) of the United States, or District of Columbia.

NOTE: Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by our regulations at 42 CFR §§ 410.26 and 410.27.

Will Medicare Cover Chiropractors Performing Acupuncture Services?

Many chiropractors, excited at the prospect of providing acupuncture services for Medicare patients need to review the rules carefully, as the requirements are complex. A chiropractor who has completed the 100-hour acupuncture course and examination approved by the American Chiropractic Association (ACA) and the National Board of Chiropractic Examiners (NBCE) DOES NOT meet the Medicare requirement for who can perform these services, as noted in the following comment published in the "Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N)" :

"Comment: One commenter requested chiropractic doctors who have completed the 100 hour acupuncture course and examination approved by the American Chiropractic Association (ACA) and the National Board of Chiropractic Examiners (NBCE) be included in the list of personnel able to furnish acupuncture in the studies.

Response: CMS notes that the requirements for chiropractic acupuncturists vary widely from state to state. CMS also notes Medicare covers manual manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor (or other qualified provider). Medicare does not cover other services or tests ordered by a chiropractor, including acupuncture. However, if a chiropractor fulfills the requirements in section I of this decision memo as auxiliary personnel, they would be eligible to furnish acupuncture “incident to” a physician’s service." 

The National Coverage Determination (NCD) categorizes chiropractors as auxiliary personnel, as Medicare does not recognize their authority to order other services (e.g., tests, x-rays, acupuncture services) but only covers a short-list of services they can provide. As such, chiropractors must meet ALL of the following requirements to perform acupuncture services for Medicare beneficiaries with chronic low back pain:

1. Must have a Masters or Doctoral-level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM) (not the 100-hour ACA approved course and NBCE exam)
2. A current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e., Puerto Rico) of the United States, or District of Columbia.
3. Meet the regulations as stated in 42CFR §§ 410.26 or 42CFR §§410.27 regarding incident-toaphysician’sornonphysician practitioner’s (NPP) service
   1. Must have a physician or NPPs (e.g., physician assistant (PA), nurse practitioner (NP), certified nurse midwife (CNM) or clinical nurse specialist (CNS)) order for the services (Medicare will not cover acupuncture services ordered by a chiropractor)
   2. Must perform the services (98710, 98711, 98713, or 98714) as written in the order without changes initiated by other than the ordering provider
   3. Must be performed under direct supervision of the physician or NPP (in the same office where the physician or NPP is immediately available for assistance)
4. Must document any improvements in patient functionality, as noted in the Medicare coverage guidance to show the patient is showing signs of improvement or the services must be discontinued
5. Must meet the criteria for reporting acupuncture service codes, as noted in the guidelines.

NOTE: The rules are very strict and must be adhered to in order to receive payment from Medicare.

For those chiropractors who meet ALL of Medicare's criteria, this is a great opportunity to network with providers and healthcare groups to offer acupuncture services to Medicare beneficiaries. This is a federally recognized alternative to opioid therapies that could benefit many, so take the time to communicate with those physicians and NPPs willing to work chiropractic acupuncturists. This could provide an alternative income for providers, along with improved referrals for chiropractic services.

Documentation is the Key to Success

Medicare has strict rules that require the documentation to clearly show both:

• Medical necessity for the services rendered 
• Improvement in the patient's chronic low back pain attributable to acupuncture therapy

Additionally, Medicare describes how providers may document "the reasonable and necessary nature of this service" by the following: 

• Services are delivered toward well-described and realistic goals aimed to significantly improve the patient's functional status over a reasonable and defined period of time
• Treatment based on clinical findings documented by the physician or practitioner who is managing or co-managing the care of the beneficiary's chronic low back pain
• Continuation of treatment is contingent upon progression towards treatment goals as evidenced by specific and significant objective (i.e. measurable) improvements of function and clinical findings (e.g., outcome assessment scales, range of motion)
• Treatment is discontinued if the patient is not improving or is regressing.

This means it is going to be very important that the recommendation for acupuncture services is being made specifically for chronic low back pain and documentation captures key elements to support medical necessity and continued service. Some key evaluation and documentation points to indicate improvement in function attributed to acupuncture services would include improved ability to perform activities of daily living, improved mobility, reduced opioid dependency, reduced anxiety or depression, and improved quality of life as perceived by the patient. 

It is important to note, that the CMS decision memo states, "all types of acupuncture including dry needling for any condition other than chronic low back pain are non-covered by Medicare".

When assigning acupuncture service codes 97810, 97811, 97813, or 97814, it is important to remember that acupuncture services are reported based on time and type of acupuncture (with or without electrical stimulation). To report time appropriately, it is not the amount of time the needles are in the patient's body, but rather the one-on-one patient contact time by the provider (i.e., evaluation, assessment, locating acupuncture points, preparation of the insertion sites, inserting and removing needles). 

NOTE: Several audits have found that code selection for time has been incorrectly determined by the duration of time the needles were in the patient's body.

Diagnosis Reporting 

Currently there is not a code specific to chronic low back pain in the ICD-10-CM codebook. With Medicare and many other payers requiring a reported diagnosis of chronic low back pain to support treatment with acupuncture services, it is important to understand how to properly report and sequence ICD-10-CM codes to reflect chronic low back pain. The Official ICD-10-CM Chapter-Specific Coding Guidelines in Chapter 6, B, (b), (i) states,

"Codes from category G89 may be used in conjunction with codes that identify the site of pain (including codes from Chapther 18) if the category G89 code provides additional information. For example, if the code describes the site of the pain, but does not fully describe whether the pain is acute or chronic, then both codes should be assigned."

The rules of coding and sequencing chronic pain are important for supporting medical necessity for the services provided to these patients. To correctly report chronic low back pain, coding should include: M54.5 low back pain and G89.29 other chronic pain. This provides a clear picture of the patient's condition. However, the sequencing guidelines provide further guidance, as seen in Chapter 6, B, (b), (ii), which instruct sequencing G89.29 as the principle diagnosis when the encounter is for pain management or pain control (e.g., prescription management, injection for pain control) followed by M54.5 to identify the site of the pain. However, if the focus of the treatment during the encounter is diagnostic or therapeutic for the low back and not the chronic pain, M54.5 would be sequenced first, followed by G89.29 to indicate the patient also has chronic pain. As you can see, the provider's ability to correctly document the condition and the focus of treatment during the specific encounter is important.

Compliance Plans

Maintaining an up-to-date and living compliance plan is required for any provider or organization who receives money from federal programs (e.g., Medicare, Medicare Advantage, ACA plans). If your organization will be participating in providing acupuncture services or referring them to someone who does, this is an opportunity to show proper maintenance of your compliance plan by updating it with acupuncture referrals or performance guidelines. 

Resources

As documentation is vital to supporting medical necessity and ensuring proper reimbursement, take the time to understand and review the 2021 Acupuncture Reimbursement Guide published through innoviHealth and which will be available through our store at store.innovihealth.com at the end of 2020.