Calculating Billable Units

I recently learned of an office that was audited based on the number of acupuncture sessions performed in one day. Is there a maximum number of sessions that can be performed in one day?

This is a good and timely question, as Anthem Blue Cross is taking a closer look at acupuncture billing and coding as acupuncture is more universally covered. I too, have had a few offices that have had an issue on the amount of acupuncture billed on a single date of service. This potential limit of acupuncture billing is related to the time values (15 minutes per session) associated with acupuncture. The amount of billable one-on-one units that can be charged per day is partly dependent on the number of hours per day that acupuncturist works. An acupuncturist cannot be one-on-one with more than one patient at any given time. As a result when a provider has an eight hour day there could not be more than 32 sessions of acupuncture performed, as the time frame of 15 minutes would allow a max of four per hour.

The acupuncture codes 97810-97814 all indicate 15 minutes face-to-face with the patient with insertion. In simple terms this means that the needle(s) must be inserted, but also requires 15 minutes face-to-face time with the patient. The 15 minutes is just as important as inserting the needles when it comes to the coding.

The 15 minute increment of time is defined as personal one-on-one contact with the patient. This means that the acupuncturist is in the room with the patient, is actively performing a medically necessary activity that is a component of acupuncture or electro acupuncture. The time that the needles are retained is specifically excluded for the purpose of determining time and consequently from reimbursement. Just like with massage, 97124, the time that can be billed is the time that the massage is occurring and anytime the patient is left to relax would not count towards any billable service.

Regence Blue Cross,et al., have recently published specific time requirements for acupuncture and it aligns with the timed interventions related to 15 minute physical medicine services.

Eight Minute Rule for Timed Codes – One Service

For services billed in 15-minute units, count the minutes of skilled treatment provided. Only direct, face-to-face time with the patient is considered for timed codes.

• Seven minutes or less of a single service is not billable.
• Eight minutes or more of a single service is billable as one unit or an additional unit if the prior units were each furnished for a full one.

Based on the time value it is only possible to perform a maximum of four sessions of acupuncture per hour based on the face-to-face time requirement. Further, if only 20 minutes is spent face-to-face regardless of insertions there can be no more than one code billed, as the minimum face-to-face time is 23 minutes for two units or sessions.

The expectation (based on the work values for these codes) is that a provider’s direct patient contact time for each unit will average 15 minutes in length. Pre, intra, and post-delivery face-to-face time with the patient is counted and determines the total treatment service time. If more than one 15 minute timed CPT code is billed during a single calendar day, then the total number of timed units that can be billed is constrained by the total treatment minutes for that day.

Documentation to support timed skilled intervention is required. Demonstration of skilled care requires documentation of the type and level of skilled assistance given to the patient, clinical decision making or problem solving, and continued analysis of patient progress. This may be documented by recording both the type and amount of manual, visual, and/or verbal cues used by the acupuncturist to monitor the patient during the acupuncture treatment. Another way of documenting skilled care may be to provide documented observation regarding responses before, during, and after an intervention as well as the patient’s specific response to the intervention. It is not unusual for an acupuncturist to monitor a patient’s progress with pulse or other evaluation methods while needles are inserted. Additionally any time spent manually stimulating needles while inserted would count towards the skilled intervention time.

So indeed, there can be a maximum of acupuncture services provided and billed in one day, but that is based on the total number of hours the acupuncturist is seeing patients.