The "Red Flag" & Your Claims: Billing for Multiple Services

Q: Are there any limits as to the number of services I provide per visit? I often provide multiple sets of acupuncture along with some physical therapy services as an adjunct to my care. I have heard that multiple services create a "red flag" to my claims.

That question is not uncommon and poses an interesting dilemma to providers when choosing the care for their patients and how that care is reflected in the billing and charges. Care plans should, of course, be based on the condition of the patient along with any complications or comorbidities that may affect or inhibit recovery.

One should in addition to using their own experience also be aware of what "evidence-based" protocols are available, as those are good starting points. Bear in mind guidelines are just that and not considered so rigid that care plans cannot differ, but this difference should have some valid reasons and protocol for the difference.

Within these guidelines, it predicts length, frequency and the types of care. This care generally can be defined as the acute phase and active phases of care and where each specific service fit in each phase. For instance, in addition to acupuncture, other modalities/therapies, both passive and active, are often used as adjunct treatments. Passive modalities include treatments such as electrical stimulation (surface stimulation not electroacupuncture), therapeutic heat, cryotherapy, and massage. Passive modalities are most effective during the acute phases of care, as they are typically used to reduce pain and swelling. They may also be effective during the acute phase of an exacerbation of a chronic condition.

Services common during this period might include ones as noted above with goals of reduction of pain, spasm, and enhanced circulation. Considering passive services essentially have the same goals multiple passive services to the same region likely be considered redundant, excessive and expressing no specific separate purpose.

Billing for Multiple Services

When doing multiple passive services ensure the goals of each modality are clearly distinguished with distinct separate parameters with a clear rationale and stand-alone purpose for each and they do not overlap. Standard treatment guidelines universally indicate treatment plans for patients who are at risk for developing chronic conditions should de-emphasize passive care and refocus on active care approaches. This does not limit the number of services or units but does relate to the length of the necessity of the passive services and when they have achieved their desired goals which are often within 2-4 weeks. My knee-jerk recommendation is typically one passive modality per visit as being the most typical.

The American College of Occupational and Environmental Medicine Guidelines relating to passive care and specifically acupuncture say, "Judicious short-term use of skilled, non-medical therapies may be indicated for significant exacerbations of underlying chronic pain conditions where there has been documented improvement following such treatments. Such exacerbations may be analogous to acute pain episodes. Patterns in quality studies ranging from weekly for a month to 20 appointments over six months. However, the norm is generally no more than 8-12 sessions. An initial trial of 5-6 visits is recommended in combination with a conditioning program of aerobic and strengthening exercises."

I take special note of the emphasis on active care in combination with acupuncture and specifically exercise including aerobic and strengthening protocols. Based on this guide clearly during the rehabilitation or chronic phase of care the addition of active rehabilitation with acupuncture are reasonable and efficacious. Most state regulations for acupuncture have allowances within the scope of practice that allows active therapies such as therapeutic exercise and therapeutic activities (however, verify your specific state's laws that relate to scope of practice).

Often to achieve the desired result of this type of rehabilitation a single unit of a service is not sufficient to stimulate proper adaptation and may require two units and in some instances more. The active phase of care addresses that when swelling and inflammation is reduced, the need for stabilization and support is replaced by the need to increase the range of motion and restore function. Active modalities include increasing the range of motion, strengthening primary and secondary stabilizers of a given region, and increasing endurance capabilities of the muscles. Active care focus on patients' active participation in their exercise programs. Progressive resistive exercises are considered an active therapy.

Documentation is Key

I would agree that the use of multiple passive modalities for extended periods may lend to increase scrutiny and a request for chart notes to verify the necessity and application of the passive services. Be wary that passive care is often seen as palliative but assistive to a protocol of active care. Active therapy likely will encompass only one code or service, but may have multiple units based on the level of rehabilitation and adaptation necessary. In any case high usage of multiple services may seem to be the red-flag, it is my experience that more often the length of care is the greater issue where it raises questions about the effectiveness of care.

As long as your notes can demonstrate the separate need and purpose of each service with adequate documentation their performance and the resultant improvement of functional outcomes there should be no issue related to the number of services. However, to give a direct answer, acupuncture with 1-2 added services would be a good rule to follow.

Also, it is common for the average for an acupuncturist to provide multiple sets of acupuncture per visit which is typically two and three sets per encounter. But, there may be instances where there could be only one set, but as much as four or more depending on the needs and protocols. There is no set limit by rule or law, but be sure each set is documented with face-to-face time and the points or insertions of each set.