Physician practices will now be reimbursed by Medicare for acupuncture services when provided for chronic low back pain, according to a
national coverage determination (NCD 30.3.3) issued Jan. 21.
But though the coverage kicks in immediately, you can expect your Medicare administrative contractor to take a little time getting up to speed on the new policy.
Physicians, physician assistants, nurse practitioners, clinical nurse specialists and auxiliary personnel can provide the service if they meet their state’s training 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.
CMS defines chronic low back pain (cLBP) as pain that:
- lasts 12 weeks or longer,
- is nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease),
- is not associated with surgery and
- is not associated with pregnancy.
Medicare will cover up to 12 acupuncture sessions over the course of 90 days, as well as an additional eight sessions for patients who show improvement. Medicare patients will be limited to no more than 20 acupuncture sessions a year. Treatment must be stopped if the patient shows signs that they are not improving or are regressing.
In response to a comment on the proposed NCD, CMS officials note that acupuncturists are not recognized as Medicare providers, so they won’t be able to bill Medicare directly for the service. Instead, CMS states, acupuncturists may provide the service incident to the service of a physician as auxiliary personnel.
That means they will need to provide the therapy under a plan of care established by the physician and under the direct supervision of a physician in the practice.
Medicare
first raised the possibility of covering acupuncture for cLBP a year ago as a drug-free alternative to opioids. In a
proposed coverage memo, CMS had floated the idea of requiring acupuncture providers to be involved in an approved clinical trial to qualify for coverage, but the agency ultimately dropped that idea.
The acupuncture CPT codes (97810-97813) are paid based on 15-minute units of time. Based on existing relative value units and the 2020 Medicare conversion factor of $36.086, primary code 97810 (first 15 minutes) should be reimbursed at $38 in the office setting, while add-on code 97811, which covers each additional 15-minute increment, will be paid at $28 (All fees par, not adjusted for locality).
CMS doesn’t appear to exclude acupuncture with electrical stimulation from the NCD. Those codes reimburse at slightly higher rates in the office – primary code 97813 pays $42 per 15-minute unit, while add-on code 97814 pays $34 per unit.
The new NCD raises the possibility that Medicare will also cover the new dry needle codes (20560-20561) added in the 2020 CPT manual. In its NCD memo, CMS states that it considers dry needling to be a form of acupuncture.