On January 21st, 2020, the Centers for Medicare and Medicaid Services (CMS) announced their decision to cover acupuncture for chronic low back pain. This is defined as localized pain in the lower back that persists for more than three months. The decision was momentous because it marked the first time acupuncture services could be reimbursed by Medicare.
Unfortunately, the decision also created a great deal of confusion. While Medicare now covers acupuncture services for lower back pain, there are a number of important conditions that must be met for treatment to be eligible for acupuncture billing. This makes many wonder what factors are considered for Medicare acupuncture coverage.
For example, the treatment must be administered under the “adequate supervision” of a physician, physician assistant, or nurse practitioner. This may sound simple enough, but the language used by the CMS ruling to define who may administer that treatment is deceptively complex.
Does Medicare Pay for Acupuncture?
The simple answer? Medicare doesn’t cover acupuncture for any condition other than chronic low back pain.
There are also additional acupuncture insurance billing requirements to follow, although the ruling has created the impression that any licensed acupuncturist can bill services to Medicare as long as they administer treatment in the presence of a physician, physician, assistant, or nurse practitioner. However, this is not an accurate interpretation of the CMS decision.
The ruling clearly states that a provider must be an MD/DO, physician assistant, nurse practitioner, clinical nurse specialist, or auxiliary personnel. They must also “possess a master’s or doctoral-level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM)” and hold a “current, full, active, and unrestricted license to practice acupuncture” in the state.
Some holistic practices have seized upon the category of “auxiliary personnel” and taken it to mean something akin to an independent contractor. While an independent Licensed Acupuncturist may qualify as auxiliary personnel, the CMS ruling is quite clear on how this category can administer treatment:
“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 regulations…”
The key phrase here is “appropriate level of supervision,” which is typically interpreted under Medicare guidelines to mean that the person providing the service is “incident to” a physician’s professional services or hospital services. Put simply, means that the acupuncturist is administering treatment on behalf of the physician as part of the physician’s practice. All auxiliary personnel must, therefore, be supervised by the authorized Medicare provider.
Following this logic, then, auxiliary personnel cannot directly bill Medicare for any services rendered because they are not the registered Medicare provider. The supervising physician may bill Medicare for acupuncture treatments for lower back pain (with some restrictions), but the acupuncturist cannot do so themselves.
Furthermore, since licensed acupuncturists are not currently included on the list of Medicare provider groups, there is currently no way for them to directly bill Medicare for reimbursement. Hypothetically, if they were added to the list of qualified provider groups, they would be able to bill for eligible services (currently chronic lower back pain).
Unfortunately, an act of Congress would be necessary to expand the list of provider groups. Despite several attempts to add acupuncturists to the list of Medicare providers over the past 40 years (most recently with the Acupuncture for Heroes and Seniors Act, introduced in 2015 and reintroduced in 2017 and 2019), none of them have received a committee hearing in Congress.
Current State of Medicare Acupuncture Coverage
According to Medicare, back pain can be covered if it meets the following conditions:
- It has lasted 12 weeks or longer.
- There is no known cause (not related to cancer that has spread, inflammatory, or infectious disease).
- Pain not associated with surgery or pregnancy.
As of current Medicare acupuncture coverage regulations, no other sources of back pain will be covered. However, it’s not that simple. Since Licensed Acupuncturists are still not included on the list of Medicare provider groups, most acupuncture practices will be unable to deliver Medicare-approved acupuncture until an act of Congress changes the current verbiage to include them.
Additionally, Medicare guidelines state that a Medicare-approved acupuncture treatment must be no more than 45 minutes. Insurance companies may be inclined to decline payments if they receive an insurance claim from a provider for a 60-minute treatment.
While this CMS decision has made progress, it still does not serve the acupuncturing community as effectively as it may appear since the greater majority of Licensed Acupuncturists cannot deliver services covered by Medicare still unless they are working for a physician.
Acupuncture Medicare Fee Schedule
For Medicare-covered acupuncture, guidelines stipulate that up to 12 visits in the first 90 days may be covered for Medicare beneficiaries.
Up to eight additional sessions may be covered for patients who demonstrate improvement, but no more than 20 acupuncture treatments may be administered annually. Treatment must also be discontinued if the patient is not improving or is regressing.
The current rules cover the following acupuncture treatment codes (at the current Medicare national average fee schedule)
- 97810 ($37.89): Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
- 97811 ($28.87): Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles.
- 97813 ($42.22): Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
- 97814 ($34.65): Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles.
- 20560 ($26.71): Services with needle insertion(s) without injection(s) of 1 or 2 muscle(s).
- 20561 ($39.70): Services with needle insertion(s) without injection(s) of 3 or more muscle(s).
The Future of Medicare Billing for Acupuncture Services
While most acupuncture practitioners are currently ineligible to provide Medicare-covered services for patients, there are movements in place to change the verbiage surrounding acupuncture in the Social Security act to include more of the acupuncturing community.
The American Society of Acupuncturists is currently at work drafting a bill for Congress and gathering support to make a change to the existing guidelines. In early 2021, their goal is to secure bipartisan support for the bill and organize acupuncturist advocacy campaigns to increase awareness of their bill. For more information, check out the plan here.
At Holistic Billing Services, we deal exclusively with holistic healthcare practices like acupuncture, massage therapy, and chiropractic treatment. Our team of experienced billing and coding experts understand the unique needs of holistic practices – such as acupuncturist practices – and can help you take steps to accelerate your revenue cycle management. For any questions about holistic billing, feel free to contact our team today and let us know how we can help your acupuncture practice.
Operating a successful acupuncture practice can be a rewarding and worthwhile endeavor that makes a real difference in the lives of patients. Unfortunately, it can also be quite a challenge thanks to confusion over how to bill for services effectively. The ins and outs of medical coding are complex and even a minor error can cause a claim to be denied by insurance providers.
What Are Billable Units?
Like other therapy-based practices, acupuncture practices bill their services according to Current Procedural Terminology (CPT) codes. Each code is considered a billable unit used to track what treatments have been administered. Some of these codes are service-based, representing a specific billing amount for a specific treatment. It doesn’t matter how much time it takes for this treatment to be administered. For billing and coding purposes, a service-based code has the same unit value (in this case, one unit), regardless of whether it takes twenty minutes or two hours to administer treatment (although each code has an average expected treatment time). Only one unit of service-based codes can be billed at any one time.
Many acupuncture codes, however, are time-based or multiple-unit codes. This means that each code is billed according to 15-minute increments. Most insurance providers follow Medicare guidelines when it comes to measuring this time. Often referred to as the “Medicare 8 Minute Rule” or the “Rule of Eights,” Medicare’s standards for outpatient therapy services require practices to deliver direct, one-on-one therapy for at least eight minutes to receive reimbursement for a time-based CPT code.
Medicare calculates billable units by dividing the total minutes of direct therapy time by 15 and then rounding the remaining value up or down according to the Medicare 8 Minute Rule. For instance, if a time-based acupuncture treatment (such as ICD-10 code 97811 for subsequent acupuncture) takes 20 minutes to administer, the practice would only be able to bill for one unit (the remainder of 5 minutes would not qualify for an additional unit). If the treatment took 23 minutes, however, it would be able to bill for two units (the remainder of 8 minutes does qualify for an additional unit).
Why Is Accurately Calculating Billable Units Essential for Your Acupuncture Practice?
Since most acupuncture treatments involve direct, one-on-one therapy, they are classified as time-based codes. That means that an acupuncture practice needs to be very diligent and precise when it comes to calculating billable units. Failing to accurately document the amount of treatment time could result in rejected claims or far lower reimbursements than the practice should receive.
A typical 60-minute acupuncture treatment, for example, consists of four distinct billing units:
- 1 Unit of Initial Acupuncture (Code 97810): This treatment consists of the initial insertion of needles, which obviously requires one-on-one contact with the patient. The initial insertion is expected to take 15 minutes.
- 3 Units of Subsequent Acupuncture (Code 97811): This code covers any follow-up one-on-one, direct treatment by the acupuncturist after the initial treatment.
Where some practices get into trouble is when they fail to bill for multiple units. In the above scenario, the practice could mistakenly submit this claim:
- Initial Acupuncture 97810
- Acupuncture: 15 min 97811
when it should be submitting this claim:
- Initial Acupuncture 97810
- 1 unit
- Acupuncture: 15 min 97811
- 3 units
Failing to calculate billable units correctly can cause acupuncture practices to miss out on collecting revenue for treatments they’ve provided. In this case, the practice would have missed out on two units of code 97811. Spread over multiple patients, it’s easy to see how these oversights could add up quickly and have a devastating impact on a practice’s revenue cycle management.
3 Best Practices for Calculating Billable Units
1. Know Your Acupuncture Codes
One of the best ways to ensure billable units are being calculated accurately is to become very familiar with the most frequently used acupuncture treatment codes. This goes beyond the most basic codes for initial care to include services like evaluation management codes and more specific modalities. Every practice needs to know which codes can be billed multiple times to ensure that it’s being accurately reimbursed for its services.
2. Track Your Time and Treatments Accurately
Simply knowing which codes to use and which ones can be billed as multiple units is important, but that knowledge won’t be of much use if a practice doesn’t keep detailed and accurate records about patient treatments. Acupuncture practitioners need to document how much time they spend delivering direct, one-on-one care throughout the day.
This is especially important when it comes to auditing purposes, as they need to make sure they’re not overestimating how much time they’ve spent administering treatments. Technically, a provider cannot deliver more than four billable units of care in an hour because each unit is broken into 15-minute increments. If a practice seems to be billing more units than its staff can actually deliver, it could be inviting unwelcome scrutiny by external auditors.
3. Partner With an Acupuncture Billing Service
Delivering quality can be difficult when a practice also has to dedicate time to managing billing insurance providers for reimbursements. Since there are only so many hours in the day, most acupuncture physicians want to treat as many patients as possible in that time, which leaves little opportunity to handle the sometimes tedious paperwork of billing and coding. That’s why partnering with an experienced holistic billing service can be extremely beneficial.
Outsourcing the hassle of billing and coding to a trusted partner allows an acupuncture practice to see more patients and deliver better care without having to worry about whether or not they’re calculating the correct number of billable units.
Holistic Billing Services Can Help
Holistic Billing offers a variety of billing services for acupuncture, massage, and other integrated healthcare practices. In addition to our extensive experience with insurance billing, we understand the unique needs of these practices and what sets them apart from other medical practices.
Our certified team of coders, MBAs, CPAs, and IT professionals can help you get your claims reimbursed quickly and set up a reporting dashboard that makes it easier than ever for you to get a comprehensive view of your business. Contact us today to tell us all about your practice’s unique needs.
Keeping track of treatment codes to ensure accurate medical billing can be a challenge for small holistic practices. Proper billing requires familiarity with all the relevant CPT treatment codes and how they interact with one another. Not understanding how billable units are calculated, for instance, could result in an acupuncture or massage practice not getting reimbursed properly for its services. In addition to billing and coding, however, these practices also need to make sure that they’re keeping accurate patient records to document holistic treatments.
Why is Keeping Proper Patient Records Essential for Your Holistic Practice?
Put simply, keeping proper treatment records is often a necessary step for getting paid for patient services. That’s because many insurance companies request treatment notes to ensure that the treatments being administered conform to the specifications outlined in their policies. Simply providing billing information with the proper treatment codes is usually not sufficient for an insurer to evaluate whether or not the care being administered qualifies as good practice. Without supporting documentation that provides more detail about the treatment, the claim could be considered suspect and subsequently denied.
There is often a tendency among holistic practices, such as acupuncturists or massage therapists, to believe that they do not need to keep the same records as western-style medical practices. While this may have been (somewhat) true when most patients paid for services out of their own pockets, today these practices are submitting billing claims for reimbursement to private insurance providers, all of whom are very concerned with documenting exactly what services they’re reimbursing. For holistic practices that want to start treating these patients, it is extremely beneficial for them to view their practice the same way any other professional healthcare provider would regard theirs. That means keeping detailed and accurate medical records to improve the overall quality of care, provide evidence of treatment to third-party payers, and shield the practice from potential liability.
The Benefits of Keeping Proper Patient Records
In addition to the obvious benefit of helping a practice get its billing claims approved, keeping accurate patient records is extremely valuable for auditing purposes. When a holistic practice is audited, it is typically instructed to prepare certain files for review, but the auditors will then randomly select several additional files at the time of the audit to make sure the documentation process is consistent. If an office has poor documentation, it can be very difficult to explain why treatments were administered or prove that they were necessary.
Accurate documentation is also important when it comes to providing high-quality care to patients. When patients receive multiple treatments over a period of time, there should be a record of what treatments they received, when, and why. The size of the practice should not be relevant when it comes to the extent of recordkeeping. Without accurate documentation, it can be difficult to know whether or not the best possible treatment is being administered at any given time.
For example, even if an acupuncture practice only sees three insurance patients a day, three days a week, that still means over 450 acupuncture treatments were administered over the course of a year. If a patient returns a year later for additional treatment and there is no documentation of their first visit, the acupuncturist is left to rely on memory when determining what treatment was administered. At best, this will result in highly inefficient treatments. At worst, it could open them up to liability.
3 Tips for Keeping Patient Records
Fortunately, there are a few easy tips for keeping accurate, detailed patient records. Documentation may take a little bit longer to do properly, but the benefits of accurate patient records far outweigh the inconvenience of taking five to ten minutes charting or documenting treatments after patient visits.
1. Remember the 7 Cs
In order to comply with HIPAA regulations, patient records should always follow the same basic guidelines regardless of practice type:
- Correct
- Clear
- Concise
- Complete
- Consecutive
- Comprehensive
- Confidential
2. Don’t “Carry Over” Electronic Health Records (EHR)
For holistic practices that are documenting treatments with an electronic records system, there is often an option to “carry over” information, or copy one set of medical records into another patient’s chart. While this can sometimes be a time-saving trick, it’s important to remember that copying the same notes across multiple patients is going to look extremely suspicious to an auditor (as well it should). Every treatment should be considered unique, even if the previous five patients received the exact same treatment.
3. Use the SOAP Note Format
Long utilized by medical practices to document patient treatments, SOAP notes provide an overview of the entire patient visit and give context to whatever treatment was administered. Many payers require SOAP notes to be submitted alongside billing claims to ensure that treatments were medically necessary.
There are four characteristics of SOAP notes for holistic practices:
- Subjective: An overview of the information the patient brings into the visit, including their primary complaint, patient description of symptoms, progress since the previous visit, initial pain scale value, and medical history.
- Objective: A quantifiable evaluation of the patient performed by a healthcare professional, including measurable data like vital signs, physical symptoms, laboratory results, and other clinical documentation.
- Assessment: An interpretation of the connection between the Subjective and Objective information available to produce a diagnosis of the patient’s condition.
- Plan: A description of what treatment will be administered based on the diagnosis as well as recommendations for moving forward. This information should be very specific. For instance, an acupuncturist should indicate what the pain scale value was pre and post-treatment.
Improve Your Record-Keeping with Holistic Billing Services
Keeping detailed patient records in addition to managing billing claims can be quite a handful for many holistic health practices. Every moment spent filing paperwork is time that could be spent treating additional patients and increasing revenue. That’s why partnering with a billing service like Holistic Billing can help your practice focus its attention on the most important aspects of patient care. We can help to streamline your billing process and get your claims reimbursed faster and with fewer denials while you work on expanding your business. To learn more about how Holistic Billing Services can transform your practice, contact our experienced team today for a consultation.
Holistic practices face unique circumstances when it comes to medical billing due to the ever-shifting regulatory guidelines that stipulate which holistic health services are covered by insurance, and which services remain strictly out-of-pocket. With patients paying more for their own care and insurers looking for practically any reason to deny claims (and save themselves money), monitoring collections closely is critical for staying on top of a holistic practice’s financial health and insulating it from potential changes in the regulatory landscape.
What is Net Collection Rate?
A holistic practice’s net collection rate is essentially a performance metric that measures how effective the practice is at collecting all legitimate forms of payments for services, which are typically the amount owed after all insurance company adjustments are made. The net collection rate will reveal deficiencies in this process. If a practice is struggling to collect revenue due to bad debt, late filings, coding errors, or claim underpayments, it will have a low net collection rate.
Since net collection rate is directly tied to a practice’s revenue stream, it’s one of the most important performance metrics to monitor. Typically calculated on a quarterly basis, the rate represents a snapshot of financial health and efficiency. A low net collection rate should be treated as an urgent priority because it indicates that the practice has a persistent problem when it comes to gathering revenue, which could indicate an organizational inefficiency or an issue with patient relations and communication.
Calculating and Monitoring Your Holistic Practice’s Net Collection Rate
For many holistic practices, assessing net collections on a quarterly basis may not be frequent enough to identify potential fluctuations or problems before they start to eat into the practice’s revenue. Calculating and monitoring net collection rate on an ongoing basis, whether it’s monthly or every few weeks, can help the practice flag issues quickly and prevent outstanding collections from snowballing to the point where they become unmanageable.
It starts with understanding how to assess a holistic practice’s net collection rate, which involves several important steps:
- Identify the time period that you want to monitor (e.g., 90 or 120 days). Assess data from an earlier period in which the majority of claims would be closed and cleared; ~6 months back is advisable.
- Calculate total payments (from insurance companies and patients) for the designated time period.
- Calculate total charges minus approved write-offs (e.g., due to contractual reasons, bad debt, professional courtesy discounts, etc.) for the designated time period.
- Divide your calculation in step 2 by your calculation in step 3. Then multiply by 100.
- Do this consistently (e.g., every 90 days) for a period of at least one year to get the most accurate average rate.
What Should Your Net Collection Rate Be?
A 96% net collection rate is generally considered ideal across the healthcare industry, regardless of practice type. This applies to holistic practices as well. If the rate is closer to 90% (or lower), the practice is definitely leaving revenue on the table that it should otherwise be collecting.
The whole purpose of monitoring net collection rate is to identify these problems, or, to put it another way, take advantage of opportunities. A low score indicates that some issue is getting in the way of efficient payment collections. There are a few common culprits that bring down net collection rates for a holistic practice:
- Non-Paying Patients: For some reason, the practice has a high proportion of outstanding bills that it cannot collect from patients.
- Claim Denials: One or more insurance companies are consistently denying claims for holistic services.
- Unsubmitted Claims/Unbilled Patients: Claims and bills are not being sent out promptly, which has created a significant lag between point-of-service and revenue collection.
How to Improve Holistic Practice Net Collection Rate
Depending upon the source of the problem, there are a number of solutions that a holistic practice can implement to boost its net collection rate.
1. Require Up-Front Payments
One of the easiest steps to take is to collect 100% of copayments and deductibles from patients at the initial point-of-service. This ensures that no one walks out of the office with an outstanding bill and avoids the resulting hassle of collecting payments afterward, which can be just as inconvenient for the patient as it is for you or your staff. Setting up appointment reminders that inform patients they must pay for holistic services up-front is essential for making this strategy effective. If a patient is unable to cover the cost at that time, the appointment can be rescheduled or other payment options can be discussed.
2. Educate Patients
Many patients who seek holistic medical care may not understand which services their insurance will cover and which services they will be responsible for paying. This can create a great deal of confusion when it comes to billing. To avoid any surprises, either at the point-of-service or in the event of a denied claim, it’s important to educate patients about the unique nature of holistic medical services and how their specific insurance plan regards them. Providing a brochure or reference sheet can be helpful, but patients may have many questions that require more detailed explanations. Having a staff member with the expertise and resources to field these questions can help to reduce confusion about how the claims and payment process works for holistic practices.
3. Provide Payment Options
Expanding payment options requires some investment on the front-end, but it can have a major impact on net collections over time. Mailing out a billing statement and asking patients to write a check was an inefficient collection strategy 30 years ago, and it’s even less efficient today. As consumers, patients are accustomed to being able to pay for services in a variety of ways, whether it’s by credit/debit card, through an online portal, or via a mobile app. For some patients, an installment plan might be the only way they can realistically afford holistic healthcare services that aren’t covered by their insurance provider. By providing a variety of payment options, patients are far more likely to find one that suits their needs and pay their bills promptly.
4. Reassess Your Own Process
When evaluating the reasons for a low net collection rate, it’s easy to assume that the problem stems from patients not paying their bills. In many cases, however, the issue has as much to do with the way a holistic practice handles its billing. Since these offices typically don’t have as much staff support as the average healthcare practice, holistic care providers are sometimes forced to wear many different hats. That can lead to administrative tasks like preparing insurance claims or billing patients being put off in favor of much more urgent tasks.
Unfortunately, time is of the essence when it comes to revenue collections. Taking too much time to submit an insurance claim could lead to a denial, and patients may be less inclined to pay a bill promptly when it takes a long time to arrive in their mailbox. More importantly, filing an insurance claim is a very detail-oriented process, so even the slightest error could result in a claim being denied. Putting a system in place that files claims accurately and promptly (as well as bills patients consistently) is essential for any holistic practice hoping to improve its net collection rate.
Improve Your Net Collection Rate with a Holistic Billing Service
Whatever the causes of a low net collection rate, partnering with a reputable holistic billing service is one of the fastest and easiest ways to turn this key revenue metric around. An experienced billing service can overhaul the way a holistic practice prepares and submits claims to payers to minimize the rate of denials. Turning the billing process over to a third party also frees up time for office staff to focus on providing the best service and care possible. Instead of spending hours on the phones trying to collect outstanding payments, they can focus on expanding the holistic practice’s patient base and improving services to better retain the patients it already has.
Holistic Billing Services has years of experience handling coding and billing issues for holistic health providers, with a special focus on acupuncture, chiropractic, and massage practices. We understand that each practice is unique and requires a customized solution that aligns with its long-term goals. That’s why we work closely with our clients to help them set up the solutions that meet their specific needs and allow them to deliver the best holistic care possible. To find out what we can do for your holistic practice, contact our team today for a consultation.