Providing Mulitple Sets of Acupuncture in a Single Visit

Q: Is there a limit to the number of sets of acupuncture I may provide in a single visit?

Per the Current Procedural Terminology (CPT) code book, there is no indications for limits to the number of sets or units of acupuncture that may be applied. However, it does make it clear to qualify for each set you must spend 15 minutes face to face with the patient with the insertion of needle(s).

However, that is only part of the puzzle and answer as CPT does not make the decisions on reimbursement and that, of course, is done by individual insurance payers. To unravel let's make some considerations.

In My Experience I Have Found ...

The level of care of an individual patient should be determined by the specific needs of their condition and its severity, complexity, chronic-acute nature, etc. With that consideration, the number of sets should depend on the necessity to properly address the condition being cared for.

From my experience in teaching continuing education on ethical coding and billing for acupuncture for close to 20 years that the average number of sets on a visit is between 2 and 3, with the actual number closer to 2 than to 3. That does not mean that some providers have instances to do more it simply is the average.

Historically the issues of sets have only been in place since 2005 when the codes updated as prior acupuncture was identified with a single code (one for manual and one for electrical) that was denoted for one unit regardless of the time spent or the number of needles/sets. The codes were updated to better reflect the level of service provided wherein a provider would have an ability to demonstrate the actual time and number of sets of needle(s) utilized.

This change was not intended to increase revenue for acupuncture, but to more accurately have nomen-clature that more accurately reflected the service and not simply a single code catch-all. Much like timed physical medicine services where the codes and units will accurately reflect the number of services provided.

Until recently, I have not noted any plans that placed an actual limit to the amount of acupuncture that could be provided. But I have noted a decided increase in audits for acupuncture providers who bill 4 sets or more per visit routinely. This is not to correlate with any wrongdoing but simply that reviews are greater when there are higher than the average number of services applied.

Unfortunately, a number of these offices failed the audit due to lack of proper documentation that did not indicate adequate and specific face to face time nor the specific points for each set. Note to bill 4 sets of acupuncture would require at least 53 minutes face to face with the patient (8-minute rule for 15-minute codes) and 4 separate and distinct insertion of needle(s).

An Incorrect Assumption

The time of an acupuncture visit often will meet that amount of time however it must be correlated that the only time that counts is the face to face time and the time the patient is "resting" on needles is excluded for the time face to face. I found many providers assumed as long as the patient was there for 60 minutes and they did acupuncture it would equal 4 units and that, of course, is incorrect.

Let's not get too far into the weeds and get specific to your question on limits. United Health Care has recently published limits in their reimbursement guidelines for acupuncture to the following. Manual acupuncture 1 initial set and up to 3 additional sets of manual acupuncture, meaning a maximum of four. For electrical acupuncture 1 initial set and 2 additional sets for a maximum of 3.

Also, Triwest who manages the VA claims under VA Choice and Patient Community Care (PC3) has most recently allowed a maximum of 2 sets whether manual or electrical on their latest authorization for standard episodes of care. There was also some information I received recently on Prime West Health in Minnesota who too is indicating their expectations or standard for acupuncture is 2 sets.

I would first and foremost indicate to any acupuncture provider the care plan of your patient and the level of services be dictated by the specific needs and some may require one and others several more, but be mindful of plans that may have limits so you are simply aware of the maximum allowed.

Further, we must as a profession be acutely aware of how we are perceived and my hope is we do not fall into a category where we have a pun that states it only takes one acupuncturist to change a light bulb but that it takes 5 sets to do it. This may not be a major issue considering the average is closer to 2 but we must be vigilant in maintaining an ethical and proficient use of our services so that we can remain a clear and effective alternative for outcome and cost.