There is a myth going on that an acupuncturist cannot be paid for an initial office visit, an evaluation and management code, either separately or on the same day as an acupuncture service under 97810-14 CPT codes.
The key to being paid for an evaluation and management service code (E/M) is to understand the key for E/M decisions is in the COMPLEXITY of the medical decisions being made. Most acupuncturists do not purchase the CPT code book because they only use four CPT codes in addition to the E/M codes. However, the preamble to the E/M section in the CPT code book goes into a lengthy explanation of how to properly use the evaluation and management codes.
Let’s be candid. Not all patients who see a physician will have the same complexity of signs and symptoms requiring the identical clinical medical decision making. Depending on the problems presented, some new patients only require medical decision making of moderate complexity; others may present with only a low complexity of medical decision making; and from an audit perspective only a few patients require medical decision making of high complexity. See CPT codes 99201-99205 for the full explanation.
The Federal Government and private insurers look for physicians to bill in a “bell shaped” curve, a distribution of all E/M codes. Thus, a patient with an already diagnosed problem of sciatica may only have low complexity or straightforward medical decision making. Converting all patients into Level Five new patient visits asks for trouble.
So the key to avoiding or prevailing on an audit or chart review is good clinical documentation. Just changing a few words around on medical software is NOT sufficient documentation.
Most state ethics or regulations require documentation which substantially justifies the items and services rendered. Failure to correctly document your notes can lead to both Federal and State criminal and civil fines or other penalties. See 42 USC 1320(a)et seq. for example.
What is substantial documentation? It comes down to good old fashion SOAP notes.
Follow this example, as a physician:
A patient comes to you with a history of a triple spinal fusion at C 4/5; 5/6 and 6/7 that is twenty years old; the fusions are stable, but were performed two decades prior. The patient complains (Subjective) to you of pain down his entire right arm, down the neck, across the right shoulder with numbness in half his middle finger, pointer and thumb. You examine the patient and find four (4) plus muscle spasms down the affected areas coupled with numbness and weakness along the affected anatomy, with specific locations of trigger point pain which the patient responds to upon examination. Your (Objective) findings were just found by you. Now comes your (Assessment): Is this cervical radiculapathy or is it an ulnar nerve? Remember those finger complaints. So you exam the elbow. Tap it and pain radiates into those same three fingers.
This is NOT a Level Five office visit because the nature of presenting symptoms does not have any comorbidity factors, nor a high probability of severe, prolonged functional impairment. (Remember, the patient has a 20 year problem; no new falls or new acute symptoms or recent injury), so this is most likely a Level Four E/M code - medical decision making of moderate complexity. You did a comprehensive examination and took a detailed history. Remember, by CPT coding rules, Time is NOT a deciding factor in selecting an appropriate CPT code.
Face-to-face time is an explicit factor done to ASSIST in the selection of an appropriate CPT code.
You formulate a (Treatment) plan. The patient needs physical therapy, perhaps an EMG for the possible carpel tunnel syndrome, and acupuncture. If you render any of those services on the same day as the office visit, you may have to use a coding modifier attached to the E/M code. If this patient had acute new pain into his hand and fingers, and is loosing new functions with that hand, this probably can justify a Level Five visit. See the CPT code book for complex medical decision making discussions.
If you submit this SOAP note to insurers you should be paid for the Level Four office visit.
If you are constantly denied E/M Billings, ask Medicare or private insurance to give you an educational visit. They will do so and they love the opportunity to actually visit a provider who wants advice on billing instructions.
You can also combine claims and get a Medicare or private insurance reopening of denied claims. Providers rendering too many Level Five codes face a great risk of audits. Once the audit begins, they can go back four to six years in your paid claims under some Federal and or State rules.
The time to hire an attorney is when you see a pattern of denied claims. An experienced attorney can sometimes speak with utilization managers or medical directors to resolve issues.
How is a provider audited?
That answer is simple. Insurers and Medicare keep track of every time you use a CPT code compared to your peers. Once you exceed screening parameters, you may face an audit. The second way most providers are audited is when the patient calls your office to contest a charge or service rendered. If your office manager or you ignore that patient inquiry. that patient can become irate and call Medicare or private insurance and thus the audit results.
Providers should read the CPT book for correct E/M Billings and consult their experts before problems arise. This article is not intended as specific legal advice, and all opinions are of this author.
For more in-depth explations of how physicians and acupuncturists can be paid for Evaluation and Management Services, contact Jonathan Schuman at email@example.com.
Jonathan D Schuman, Atty
West Palm Beach, FL
American Health Lawyers Association
Formerly employed by Office of General Counsel, Medicare Attorney