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Acupuncture for Chronic Low Back Pain

Published on 

Monday, April 20, 2020

 | Recovery Auditor 
 | Coding 
 | Documentation 

“I am convinced that acupuncture is going to be one of the greatest contributions that any group of people has made to the future of all medicine, if it is handled correctly by the people of the Western World.”

  • 1972 Quote by Dr. W. Kenneth Riland, Personal Physician to President Nixon

 

Background

In May 1980, CMS issued a national non-coverage determination for acupuncture (NCD30.3). Since then they have issued non-coverage determinations for acupuncture for fibromyalgia (NCD 30.3.1) and acupuncture for osteoarthritis (NCD 30.3.2).

In a July 15, 2019, Press Release, CMS announced their proposal to cover acupuncture for chronic low back pain (cLBP) as a potential alternative to opioid use, while data is collected on patient outcomes. HHS Secretary Alex Azar noted, “Defeating our country’s epidemic of opioid addiction requires identifying all possible ways to treat the very real problem of chronic pain, and this proposal would provide patients with new options while expanding our scientific understanding of alternative approaches to pain.”

On January 15, 2020, CMS released the Final Decision memo for acupuncture for cLBP (CAG-00452N).

CMS indicated in a related Press Release they had “conducted evidence reviews and examined coverage policies of private payers to inform today’s decision.”

 

MLN Matters MM11691: April 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

MLN MM11691 describes changes to and billing instructions for various payment policies implemented in the April 2020 Hospital OPPS update. Included in the update is guidance about the change in status indicators for acupuncture as a result of NCD 30.3.3. Following is an excerpt from the article specific for Acupuncture:

Effective January 21, 2020, Medicare covers acupuncture and dry needling for beneficiaries with chronic low back pain…Based on this recent coverage determination, CMS revised the OPPS status indicator and APC assignment for the CPT codes describing acupuncture and dry needing services from “E1” (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type) to “S” (Paid under OPPS, separate APC payment) and “N” (Paid under OPPS; payment is packaged into payment for other services. Thus, there is no separate APC payment.)

 

Table 2 – Acupuncture and Dry Needling CPT Codes for Newly Covered by Medicare

CPT CodeLong DescriptorOPPS SIOPPS APCEffective Date
20560Needle insertion(s) without injection(s); 1 or 2 muscle(s)S573101/21/20
20561Needle insertion(s) without injection(s); 3 or more musclesS573101/21/20
97810Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-on contact with the patientS573101/21/20
97811Acupuncture, 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)NN/A01/21/20
97813Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patientS573101/21/20
97814Acupuncture, 1 or more needles; with electrical stimulation, ach 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)NN/A01/21/20

You can learn more about what is covered, what is noncovered, and who can furnish acupuncture for the Medicare Fee-for-Service population as detailed in NCD30.3.3 in a related MMP article.

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.