How to Avoid an Audit: The Five-Letter Word You Dread

Question: I have read about potential audits of acupuncture claims and that some offices have been requested to repay money to insurance carriers. Is this actually true and how do I make sure this does not happen to me?

Yes, insurance carriers will or may request records to verify the services that were billed were documented and performed adequately. Frankly, this is not common but is something a carrier may do when a claim or a pattern of claims are unusual.

In this instance, I would refer to high-level evaluation and management codes 99204, 99205 and 99215. While this level of coding is not prohibited by a licensed acupuncturist it is not common and may trigger a request for information to verify that high level of service was performed. Additionally, other triggers would include a high volume of sets of acupuncture particularly four or more, or multiple physical medicine and rehabilitation services in addition to acupuncture. Typically more than two added physical medicine services are not necessary.

Not that there is any inherent error or improper use assumed when these patterns appear but when done with a high frequency or regularity, it may create a question on the insurance side.

Furthermore, long-term care for the non-severe or acute condition may too lead to a request for documentation.

I consult thousands of acupuncturist every year and will always first tell the acupuncturist to not panic or fear the request as generally this request is solely to verify that the services billed were performed. These reviews, at least initially, are not typically a review of the necessity of services but that they were performed. In that vane, I believe offices do truthfully bill for the services they did and should not have an irrational fear. However, it is important to verify that the chart notes are compliant and that each service does adequately reflect the services billed.

Being you are an acupuncturist I would assume acupuncture is likely performed primarily. To properly document acupuncture services there are two elements required. Face-to-face time with the patient and the insertion of needles. Therefore it is imperative that both time and needles (sets) be documented adequately. For instance, for one set there must be at least 8-22 minutes face-to-face and one or more needles inserted as part of that set. Note, this is referencing the CMS eight-minute rule for timed services.

For a second set, there must be at least 23 minutes of face-to-face time and two distinct sets (insertions) of acupuncture. I suggest to start a timer or reflect the time that the acupuncturist is in the room with the patient and performing any activity that is part of the acupuncture service. Each set should also be clearly indicated as well. Bear in mind this time essentially encompasses all the time the acupuncturist is with the patient except for the time spent on separately billed or performed physical medicine and rehabilitation services.

This face-to-face time would or may include a review of history, day to day evaluation, hand washing, choosing and cleaning points, inserting and manipulating needles, removal, disposal as well as completion of the chart notes while the patient is present). The time that the needles are retained is specifically excluded for the purpose of determining the time and consequently from reimbursement.

Make sure the time fits the time or units associated with timed services as follows: 8-22 minutes per one unit or set, 23-37 minutes per two units or sets, 38-52 per three units or sets, 53-67 minutes per four units or sets and so on.

If an evaluation and management (E&M) code were billed be sure that the E&M is clearly distinct and separate from the preservice and post-service work associated with acupuncture service(s). Note an initial evaluation and one approximately every 30 days is typical. If it is shorter than this period be sure there is adequate information to indicate that a separate E&M above and beyond the acupuncture preservice et al was needed and documented. Please refer to the 1997 E&M guidelines for the level of E&M service and do not bill an E&M based on time face-to-face time but the level of evaluation performed and documented. For instance, per the 1997 guidelines 99203 or a 99214, there must be detailed history with an examination that documents at last 12 bullets or elements on examination.

Exception to the Rule

The exception is for counseling, where counseling represents 50 percent or more of the time of visit you may use the time as the controlling factor for the level of E&M code and not the bullets or elements. Please, note by example if you do three sets of acupuncture which means at least 38 minutes face-to-face you would have to perform counseling that is at least an additional 38 minutes beyond the time for acupuncture which though is possible is not likely. Counseling is part of the acupuncture service and only if it hits the 50 percent threshold is a separate E&M billable.

Additionally, if any physical medicine or rehabilitation services were performed those too require specific documentation to verify services were performed. Supervised services 97010 to 97036 though not timed must adequately be documented. For instance, infra-red heat 97026 would need to indicate where it was applied, the intensity if applicable and time. Time is not essential to the billing but minimum documentation should include the length of application your edification to ascertain time needed for adequate response and future use.

If a therapeutic procedure such as massage 97124 or manual therapy 97140 those being hands and face-to-face the documentation must include the type of service, the area of application and the time it was performed. Being this is a timed service it follows the same eight-minute rule as noted for acupuncture.

Also, time is cumulative so if you do 10 minutes of massage and 10 minutes of manual therapy on the same visit the total time is only 20 minutes which means only one unit is billable. Meaning only one service may be billed not both, as not until 23 minutes is spent and at least 8 minutes for either could two units be billable. With any physical medicine service, there should also be documentation of the purpose and goals of the service as well.

If an Audit is Requested

I would not fear an audit as they are simply looking to ensure what was billed was performed. In fact, some insurance plans will pay fair and reasonable amounts for those services and I would not eliminate or disqualify that patient simply by "fear" of a request for notes. You did the service be sure you document it. I have aided multiple offices with record keeping and these audits and have never had an issue as long as the documentation is present. The offices who have had an issue simply failed to demonstrate the services they provided. Doing such is not hard but often offices are not aware of some the nuances as noted.

I will recommend regardless of insurance billing, this level of documentation is required by professional standards and your state board of acupuncture or medicine. I find promote the documentation of the effectiveness (medical necessity) of acupuncture is easy, as a patient's response to acupuncture often results in much less pain and consequently it is not hard to show functional improvement as that is always direct the result of the reduction of pain.