Medical Billing Services: Top 2 Reasons You're Not Getting Reimbursed for Code 97810

If you are an acupuncturist, you are already familiar with 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 treatment. Verified time means that the time increments are documented in the patient's chart for the correct date of service. 97811 is used for each additional 15 minutes spent administering treatment. This does not include the time the patient spends laying idle on the table. For instance, if a front treatment is done without any other services, then 97810 should be billed. However, if the patient receives front and back treatment, 97810 and 97811 should be used.

Now, that we explained what procedure codes 97810 and 97811 mean, we can begin to discuss the top 2 reasons why you are not getting reimbursed from Insurance companies.

Claim sent to Medicare or Medicaid

Neither Medicare nor Medicaid will reimburse for acupuncture claims. Medicare and Medicaid are excellent insurance programs for the young, poor, sick and old; However the insurance plans do not cover everything. Medicare determines medical necessity when they receive the claim. However, Medicare does not consider acupuncture, holistic medicine, alternative therapies and homeopathy to ever 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 full bill if you receive these services. Many acupuncturists willingly discount their prices for non-insurance patients.

Medicare also offers supplemental plans, which allows someone to gain coverage where there once was none. Medicare advantage plans may offer acupuncture, and alternative therapies. Even though, Medicare advantage plans cover acupuncture, the service will only be payable if it is determined to be medically necessary, and if the services is performed by a licensed healthcare professional who participates in Medicare. To find out if your Medicare patients have acupuncture insurance, perform Benefits Verification. An experienced and competent medical biller should know whether a claim will be paid or not before it's transmitted to the insurance company. A thorough and documented Benefits Verification will give you the insight you need to make that determination, each and every time.

Wrong Procedure Code

There are four codes that are greatly used by acupuncturist. We have already discussed two of those codes, 97810 and 97811. However, there are two more additional codes, which is 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 performing the procedure. 97814 is used for each additional 15 minutes spent using electrical stimulation on one or more needles. Oftentimes, licensed acupuncturists simply code the procedures incorrectly. That is why keeping good records is a must for acupuncturist. For instance, if a provider performs general acupuncture, and then performs acupuncture with electrical stimulation, how would you bill that visit? Many providers believe the correct way to code this visit is with 97810 and 97813. However, 97810 and 97813 is used for the initial 15 minutes. Therefore, a determination must be made about what procedure was performed first. Since, general acupuncture was performed first, we will bill 97810 for the first procedure, and 97814 for an additional 15 minutes of acupuncture with electrical stimulation. This is the correct way to bill this scenario.

Acupuncture insurance billing can be tricky for many medical billing services and in-house staff. Physicians can have over 50% of their claims denied, simply because they have not learned how to properly code procedures. However, with thorough research about acupuncture coding and how to properly use them, experienced medical billing services can help you to expect consistent reimbursement from insurance companies.