Acupuncture, Medicare

Applies to

  • Priority Health Medicare Advantage (Individual, D-SNP and Employer Group)

Definition

Acupuncture is the selection and manipulation of specific acupuncture points through the insertion of needles or "needling," or other "non-needling" techniques focused on these points. 

Acupuncture coverage

Effective Jan. 21, 2020, Priority Health, in accordance with guidance from the Centers for Medicare and Medicaid Services (CMS) covers the use of acupuncture for Medicare members with chronic low back pain (cLBP). Coverage of this benefit is intended to reduce the use of opioids for cLBP.

cLBP is defined as:

  • Lasting 12 weeks or longer
  • Non-specific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, or infectious disease, etc.)
  • Not associated with surgery
  • Not associated with pregnancy

Priority Health covers up to 12 visits over a 90-day period for members with cLBP. An additional eight sessions will be covered for patients demonstrating improvement. No more than 20 acupuncture treatments may be administered annually.

Treatment must be discontinued if the patient is not improving or regressing.

All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.

Who can administer acupuncture?

Per CMS guidelines:

  • Physicians may furnish acupuncture in accordance with applicable state requirements.
  • Physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have:
    • A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and
    • Current, full, active, and unrestricted license to practice acupuncture in a state, territory, or commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.

Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by CMS regulations at 42 CFR §§ 410.26 and 410.27.

Acupuncture billing

Approved CPT codes

  • 97810 - Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
  • 97811 - Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)
  • 97813 - Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
  • 97814 - Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)
  • 20560 - Needle insertion(s) without injection(s); 1 or 2 muscle, also known as dry needling or trigger-point acupuncture, does not involve the administration of injectable therapeutic agents
  • 20561 - Needle insertion(s) without injection(s); 3 or more muscles, also known as dry needling or trigger-point acupuncture, does not involve the administration of injectable therapeutic agents

Billing for visits 13 - 20

Priority Health covers an additional eight sessions (beyond the initial 12 sessions), for patient demonstrating improvement. For these additional sessions, the provider must bill using the KX modifier to indicate the patient is improving and that the visits are medically necessary as justified by appropriate documentation in the medical records.