Samuel A. Collins
a question: I’ve had some success securing bills, and I accept some very good paying plans. However, many of the plans don’t seem to work well, so I avoided them as I suggested in a previous article. I’ve been getting random denials and I hope you have a list of common errors or denials so I can improve how I file my claims and avoid denials or payment delays.
I applaud your success and realization that insurance doesn’t require a “take one, take all” approach, but rather you can choose which plans you accept and which you don’t. Yes, I have a list that is a good starting point for new and even experienced practitioners to use. In my experience, the following issues account for about 75% of the reasons acupuncture claims are denied or not paid properly.
Improper diagnostic code
The most common denial of acupuncture claims is the absence of a diagnosis that is part of the payer’s payroll. For example, CIGNA and Aetna publish a list of codes for billable acupuncture providers, but if you code outside those parameters, you will be automatically rejected. Note that the symbols in these lists contain some crossover, but some symbols are covered by one but not the other.
For example, CIGNA has a large list of spine-related codes that are not limited to pain, including spondylosis, disc, radiculopathy, dorsopathy, sprains, strains, etc., but Aetna is limited to the standard low back pain code M54 .50 though M54 .59, or neck pain M54.2. If Aetna is billed using the codes listed for CIGNA, this will be an automatic denial.
Keep in mind that of all the specific coding noted by CIGNA, although it may allow for a broader granulation of diagnosis, these conditions begin with “pain” and Aetna simply codes the area of pain in the spine without differentiation. Interestingly, Aetna covers TMJ and jaw problems, but CIGNA does not.
Before assuming diagnostic coverage, do some checking from a reliable source that will help determine which codes are or are not paid by the plan. It’s different whether it’s ASH, HealthNet, Anthem, UnitedHealthcare, etc. For this reason, I recommend going back to your list of shared codes and seeing whether or not they are payable and from which payers.
I always come back to knowing it’s covered; Don’t guess, and reassure your patient when there is a boost or not.
In addition, make sure that your diagnosis is accurate and contains the correct number of letters and numbers, as they may vary from three in length to as many as seven. Note that the diagnostic set will contain letters And Preparation.
One final point regarding diagnosis: Check every October to see if there have been updates, revisions, or deletions to your common codes, as diagnostic codes can be updated (changes, additions, and deletions) every year.
For example, when the code for low back pain changed from a four-letter diagnosis to a five-letter diagnosis, claims billed with the old codes were automatically rejected, which was a major problem for acupuncture providers.
Lack of appropriate CPT rate
The second most common reason for denial relates to Current Procedural Terminology (CPT) codes and lack of appropriate modifiers. The No. 1 issue with CPT relates to the coding of the examination (Evaluation and Management – E&M) when performed on the same day as acupuncture or any treatment.
In this case, E&M codes 99202-99215 would require a modifier of 25 to prove that the test was higher than the daily assessment associated with acupuncture. Without this modifier, it’s automatic denial – which is why many new acupuncture providers feel frustrated, as they assume they “don’t get paid for the tests” and don’t realize it’s a failure in their coding.
Another denial of CPT that occurs is the failure to include the GP modifier, “permanent treatment,” in physical medicine codes. Treatment refers to physical medicine and rehabilitation codes (often referred to as physical therapy codes) 97010 through 97799.
These codes for plans including UnitedHealthcare and all its affiliates, Anthem Plans, and VA (Veteran Community Care) claims require a GP adjustment or will be denied. Note that other plans like Aetna, CIGNA, et al. no Requires use of GP modifier; It should not be included in any claims other than those stated.
Both rates 25 and GP do not change the value or payment of the service, but indicate that it is a payable service; Otherwise, the claim will be automatically rejected.
Coding for acupuncture
Another thing that makes this list is the acupuncture coding. There are four codes to describe acupuncture: two manual (97810 and 97811) and two electrical (97813 and 97814). These symbols represent the initial group or insertion and subsequent groups added.
Denial is common when electroacupuncture and manual acupuncture are combined in the same visit. There could be just one Initial insertion of needles at each session daily; Any added groups must be encoded with subsequent symbols.
Therefore, according to CPT, you should never use numbers 97810 and 97813 on the same claim. If the first set is manual, code 97810, and if the next set is electric, code 97814. You can code 97810 as 97811 or 97814. The same goes for 97813; It can also be coded as 97811 or 97814.
A simple rule of thumb is to never combine the numbers 97810 and 97813 in one claim for acupuncture services because these two codes describe first 15-minute treatment by inserting one or more needles.
Editor’s note: Do you have a question about billing? Email it to Sam at sam@hjrossnetwork.com. Your submission is an acknowledgment that your question may be the subject of a future column.