Neurology & Pain Management Coding Alert

Question: We're receiving rejections from Blue Cross Blue Shield, 1199, United Health Care, and other carriers for acupuncture claims. Is the problem our diagnosis coding, perhaps, or is something more going on?


North Carolina Subscriber
Answer: Any number of problems could be causing your claim denials.

CPT introduced four new acupuncture codes for 2005:

97810 - Acupuncture, one or more needles, without electrical stimulation; initial 15 minutes of personal one-on-one contact with the patient

+97811 - ... each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (list separately in addition to code for primary procedure)

97813 - Acupuncture, one or more needles, with electrical stimulation; initial 15 minutes of personal one-on-one contact with the patient

+97814 - ... each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (list separately in addition to code for primary procedure). At the same time, CPT deleted two previous acupuncture codes: 97780 (Acupuncture, one or more needles; without electrical stimulation) and 97781 (...with electrical stimulation).

Codes 97810-97814 became effective on Jan. 1, 2005, and are not valid for any prior date of service. Therefore, if your claims are for dates prior to Jan. 1, using 97810-97814 will trigger immediate rejection.

Covered diagnoses vary by payer and, potentially, by various plans within a payer. For example, an HMO product may not allow coverage for alternative treatments, while a PPO product from the same insurance company may.

Unlike Medicare, which publishes local coverage determinations that include allowable diagnoses for covered procedures, many commercial carriers do not have their coverage determinations easily accessible. Some commercial payers have Web sites specifically for providers that are participating, and they may have access there, while other nonparticipating providers or consultants would not have access to this area.

Talk with your payer provider representative to see if the payer has published guidelines for acupuncture. Also, you might want to find out exactly why the payer denied your claim (such as, medical necessity, frequency, noncovered service, inappropriate provider, etc.).

Learn more: For complete information on acupuncture codes 97810-97814, see "Pin Down Your Changes for Acupuncture Reimbursement With Better Documentation," Neurology Coding Alert, May 2005, pp. 33-35.

For more information from Aetna on acupuncture coverage, see www.aetna.com/cpb/data/CPBA0135.html.

To learn about insurance companies that cover acupuncture, see www.acupuncture.com/News/Insuranc.htm.