Question: I have had some success billing insurance, and accept some very-well-paying plans. However, several plans do not seem to work well, so I have avoided them as you suggested in a previous article. I have been getting random denials and hope you have a list of common errors or denials so I can improve how my claims are submitted and avoid denials or delayed payment.
I applaud your success and realization that insurance does not require a “take one, take all” approach, but rather that you may choose which plans you accept and which you do not. Yes, I do have a list that is a good starting point for new and even seasoned practitioners to use. In my experience, the following issues represent about 75% of the reasons acupuncture claims are commonly denied or not paid properly.
Improper Diagnostic Code
The most common denial for acupuncture claims is not having a diagnosis that is part of the payer’s payable list. For example, CIGNA and Aetna publish a list of codes for acupuncture providers that are payable, but if you code outside those parameters, it is an automatic denial. Note that the codes on these lists have some crossover, but some codes are covered by one and not the other.
For example, CIGNA has a large list of spinal-related codes not limited to pain, including spondylosis, disc, radiculopathy, dorsopathies, sprain, strain, etc., but Aetna is limited to the standard lower back pain code M54.50 though M54.59, or neck pain M54.2. If Aetna is billed with the codes noted for CIGNA, it will be an automatic denial.
Keep in mind that all the specific coding noted by CIGNA, while it may allow a broader granulation for diagnosis, those conditions start with “pain” and Aetna simply codes the spinal region of pain without differentiation. Interestingly, Aetna covers TMJ and issues of the jaw, but CIGNA does not.
Before assuming a diagnosis is covered, do some verification from a reliable source that aids in specifying which codes are or are not payable by the plan. There is variation whether it is ASH, HealthNet, Anthem, UnitedHealthcare, etc. For this reason, I recommend cross-referencing your common code list and knowing whether or not they are payable and by what payers.
I always ascribe to knowing it is covered; don’t guess, and assure your patient when there will or will not be a payment.
Additionally, makes sure your diagnosis is accurate and has the correct number of characters and digits, as they may vary from as little as three in length to as many as seven. Note that the combination of a diagnosis will have letters and numbers.
A final point related to diagnosis: Verify every October that there has been no update, revision or deletion of your common codes, as diagnosis codes can update (changes, additions, deletions) every year.
For example, when the lower back pain code changed from a four-character to five-character diagnosis, claims billed with the old codes were automatically denied and this was a major issue for acupuncture providers.
Lack of Proper CPT Modifier
The second most common reason for denial relates to the Current Procedural Terminology (CPT) codes and the lack of the proper modifiers. The #1 issue with CPT relates to the coding of an examination (evaluation and management – E&M) code when done on the same day as acupuncture or any treatment.
In that case, E&M codes 99202-99215 will require a modifier 25 to demonstrate the exam was above and beyond the day-to-day evaluation associated with acupuncture. Without this modifier, it is an automatic denial – and the reason many new acupuncture providers are frustrated, as they assume they just “never get paid for exams” and do not realize it is a failure of their coding.
The other denial for CPT that is occurring is the failure to include the modifier GP, “always therapy,” on physical medicine codes. By therapy, I am referring to physical medicine and rehabilitation codes (often referred to as physical therapy codes) 97010 through 97799.
These codes for plans including UnitedHealthcare and all their affiliates, Anthem plans, and VA (Veteran Community Care) claims require modifier GP or they will be denied. Note that other plans such as Aetna, CIGNA, et al., do not require the use of modifier GP; it should not be included on any claims other than the ones noted.
Both modifiers 25 and GP do not alter the value or payment of the service, but indicate that is a service that is payable; without it, the claim will be automatically denied.
Coding for Acupuncture
The other issue that makes this list is the coding of acupuncture. There are four codes to describe acupuncture: two manual (97810 and 97811) and two electrical (97813 and 97814). These codes represent the initial set or insertion and a subsequent for added sets.
Denials are common when combining electrical and manual acupuncture on the same visit. There can be only one initial insertion of the needles per session per day; any added sets should be coded with the subsequent codes.
Therefore, per CPT, you should never code 97810 and 97813 on the same claim. If the first set is manual, then code 97810, and if the subsequent set is electrical, then code 97814. You may code 97810 with 97811 or 97814. The same applies to 97813; it also can be coded with 97811 or 97814.
A simple rule of thumb is to never combine 97810 and 97813 on a single claim for acupuncture services because these two codes both describe an initial 15-minute treatment with the insertion of one or more needles.
Editor’s Note: Have a billing question? Submit it to Sam via email at sam@hjrossnetwork.com. Submission is acknowledgment that your question may be the subject of a future column.
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