Whether you’re new to insurance billing or simply need a refresher, this primer will start you off on the right foot.
Electronic claims must be submitted through a clearinghouse. A clearinghouse is an intermediary through which a provider (or group) submits claims to insurance companies. Electronic health record (EHR) systems like Office Ally, SimplePractice, and JaneApp often have a built-in clearinghouse.
Most insurance companies will accept e-claims via a clearinghouse. Electronic submission is a cost-effective and time-efficient method for submitting insurance claims. Each carrier has a unique payer ID that routes claims into their systems.
Certain carriers will only accept paper claims. PIP claims (auto and workers’ comp) should generally be printed and mailed with SOAP notes. Occasionally, you may need to mail referrals, reconsideration forms, or other documentation,
Red HCFA Forms (CMS 1500 02-12)
Some insurance companies require paper claims to be submitted on a red CMS 1500 form. American Specialty Health, Trillium, and TriWest are a few examples. When printing, use the “Actual Size” setting.
While you can treat cash patients for a wide variety of conditions, insurance will typically only cover pain diagnoses. Neck and back pain are the most commonly covered pain diagnoses. Diagnoses such as depression, infertility, and insomnia are rarely covered.
- Aetna covers a limited range of diagnoses. Their allowed diagnoses are detailed in Clinical Policy Bulletin 0135. Billing non-covered diagnoses will result in claim denial.
- Cigna is also restrictive, but covers a broader range of diagnoses. Their allowed diagnoses are detailed in Medical Coverage Policy 0024. Billing non-covered diagnoses will result in claim denial.
- United Healthcare usually covers pain and nausea (for pregnancy, surgery, or chemotherapy).
To research diagnosis codes, visit ICD10data.com. Remember, it’s not necessarily better to bill many diagnoses. A single good Dx is all you need.
In a cash practice, it’s common to bill a set dollar amount, no matter what the treatment entails. When billing insurance, each procedure must be listed as a discrete line item on a HCFA form. Multiple units can be billed as a single line item.
For best results, bill up to 4 units total per DOS, and no more than 3 units of acupuncture.
The initial unit of acupuncture can be billed with either 97810 or 97813. Additional units can be billed with 97811 or 97814.
- 97810 (initial unit)
- 97811 (additional units)
Acupuncture with e-stim
- 97813 (initial unit)
- 97814 (additional units)
- 97810 + 97811
- 97813 + 97814
- 97810 + 97814
- 97813 + 97811
- 97811 + 97814
- 97810 + 97813
Some carriers may reject the risky combinations listed above. When using e-stim, it may be best to bill all units as e-stim.
Does 1 Unit = 15 Minutes?
The answer is “yes and no”. Technically, yes. But in practice, carriers observe the “eight minute rule” for timed codes:
Acupuncture Today‘s source on the “eight-minute rule” is Regence, a regional Blue Cross Blue Shield carrier.
Carrier Fee Schedules
A carrier fee schedule lists the procedure codes the insurance company will cover, and the price they will pay for each unit.
Insurance companies often include a fee schedule in their contracts. You can also request fee schedules from the carrier’s Provider Relations department.
Pro Tip: If it’s not on the carrier’s fee schedule, don’t bill it.
Acupuncture providers may be eligible to bill for modalities such as moxibustion, cupping, infrared lamp, and manual therapy. But is it better to bill modalities as discrete line items, or factor them into pricing for acupuncture codes? It may be more trouble than it’s worth. Manage your expectations carefully.
- Cigna no longer covers procedures 97016 or 97026.
- Modalities may count against the physical therapy benefit.
Office visits are first divided into two categories: new patient and established patient.
- Bill a new patient office visit on the patient’s first visit. You can reuse a new patient office visit code if you haven’t seen the patient in 3+ years (to the day).
- Bill an established patient office visit no more than every 30 days. It is inappropriate to bill an exam on every visit.
Billing exams too often can trigger an audit. Evaluation is usually considered implicit to acupuncture procedures 97810-97814.
Can I Bill Exams on Consecutive Visits?
It’s an audit risk.
Procedure Codes for Exams
Office visit codes indicate the severity of the patient’s condition and the time required.
- 99202/99212: About 20 minutes; medical decision making that is straightforward; none to minimal amount and/or complexity of data to be reviewed; no to minimal risk of significant complications or morbidity/mortality.
- 99203/99213: About 30 minutes; medical decision making that is of low complexity; limited amount and/or complexity of data to be reviewed; low risk of significant complications or morbidity/mortality.
- 99204/99214: About 45 minutes; medical decision making that is of moderate complexity; moderate amount and/or complexity of data to be reviewed; moderate to significant risk of significant complications or morbidity/mortality.
- 99205/99215: About 60 minutes; extended history of present illness; complete review of symptoms; complete past, family and/or social history; comprehensive examination; extensive number of diagnoses or management options; medical decision making that is of high complexity; extensive amount and/or complexity of data to be reviewed; high risk of significant complications or morbidity/mortality.
Level 5 exams (99205 and 99215) carry a high audit risk, and should not be used lightly.
- Don’t bill an office visit every time you see a patient.
- Use 99205/99215 sparingly.
- Never bill for family members.
- Don’t routinely waive your patient’s copays: it is a felony.
- Before offering a time of service (TOS) discount, contact your state association to make sure it’s legal in your state. If you’re in-network, check your contract for terms related to TOS discounts. We recommend no more than a 20% discount off your insurance price. If you bill $200, collect at least $160.