Insurance Denials for Acupuncture and Examination Services
One of the most common questions we receive:
What did I do wrong if UnitedHealthcare denied my insurance claim for acupuncture and examination services, stating that the information provided does not support the billed services? I only billed for two acupuncture sessions and a re-examination (code 99213), and my treatment records indicated a 50-minute session duration.
Let's dive in to answer this question:
It's not uncommon for acupuncture providers to receive denials when their notes are reviewed because acupuncture documentation requires specific indications of face-to-face time with the patient and the time involved in needle insertion. Additionally, exams and re-exams must be documented separately from pre- and post-service evaluations related to acupuncture.
When documenting acupuncture services, it is important to specify the face-to-face time spent with the patient and the time spent on inserting or re-inserting needles. The time spent on re-insertion should be treated as additional insertion, as a new needle is inserted each time. While you mentioned that you spent 50 minutes, it is important to document how that time was spent. Was it face-to-face time actively performing the acupuncture service or examination, or was it time the patient was resting with the needles inserted? This type of denial is not uncommon for acupuncture providers when notes are reviewed.
One possible reason for the denial of your claim could be the lack of specificity in your documentation, as simply noting 50 minutes of "treatment" does not indicate how the time was spent, either on acupuncture or examination.
Important Factors to Consider When Billing Based on Time
The 15-minute time increment for acupuncture refers to the period during which the acupuncturist is directly interacting with the patient in a medically necessary activity related to acupuncture or electroacupuncture. This includes activities such as reviewing the patient's history, evaluating them, choosing and cleaning points, inserting and manipulating needles, removing and disposing of needles, and completing chart notes while the patient is present.
It is important to note that the time during which the needles are retained is not counted towards the time spent on the procedure, and therefore not eligible for reimbursement.
I recommend reviewing your documentation to determine how the time was defined and documented for each set. Keep in mind that according to the eight-minute rule for timed services in the Current Procedural Terminology (CPT), the face-to-face time for one set could be as short as eight minutes.
One should count only the minutes of skilled treatment provided when billing for services in 15-minute units. Timed codes consider only the direct, face-to-face time spent with the patient.
A single service lasting for seven minutes or less cannot be billed.
A single service provided for eight minutes or more can be billed as one unit. If previous units were each provided for a full one, an additional unit can be billed.
A unit, or a set, should have a minimum of eight minutes of direct face-to-face time that involves inserting needles (8-22 minutes equals one unit).
To bill two units (sets), a minimum of 23 minutes of face-to-face time must be provided, with no single set being less than eight minutes. Any combination that meets or exceeds 23 minutes would qualify, such as an 11-minute first set and a 12-minute second set (23-37 minutes = two units).
A minimum of 38 minutes of face-to-face time is required for billing three units (sets) (38-52 minutes = three units).
To bill for four units (sets), at least 53 minutes of face-to-face time is required (53-67 minutes = four units).
The above examples would also factor in time spent for any additional needle insertions.
A Crucial Billing Distinction: Total Time vs. Face-to-Face Time
Based on the information provided in every inquiry we have received thus far, it appears that the treatment provided to the patient lasted for 50 minutes. However, it is important to clarify how much of that time was spent actively performing face-to-face interventions that involved the insertion of needles, and how much was spent with the patient resting on the needles. If there was any non-face-to-face time during which the patient was resting on needles, it should be clearly documented in the medical record to avoid any confusion during the billing process.
If you have documented face-to-face time for each of the two sets and it meets the minimum requirement of at least 23 minutes with no single set fewer than eight minutes, it would be appropriate to appeal the denial of your claim. You should highlight the specific elements in your notes that show the time and separate insertions.
Charging for an Examination
To address the denial of an examination, it's important to note that E&M codes can be used for a separate and distinct evaluation beyond the day-to-day evaluation that's part of acupuncture. The evaluation should include a review of the patient's history and the examination of the area of care, which may involve inspection, palpation, range of motion, and other relevant factors such as tongue and pulse evaluation.
An E&M code can be used for an ongoing care plan about every 30 days. It would not be reasonable to bill for an E&M sooner than 30 days unless there was a new injury, complaint, or substantial change.
To clarify, an E&M evaluation would require a complete re-examination of the patient, including how their condition has changed since the initial visit, as well as a full evaluation that compares all the original examination elements. Additionally, an updated care plan and goals should be included. It's important to ensure that a complete evaluation is conducted and documented rather than simply stating that it is a "re-exam" without sufficient detail.
Based on your use of code 99213, what criteria did you use to justify that level of service? E&M codes are currently determined by either the time spent with the patient or the medical decision-making involved. Note that the time spent with the patient must be separate from the time spent on acupuncture. For a 99213 code, the time spent would need to be at least 20-29 minutes, or there would need to be medical decision-making involving at least two areas of complaint.
When billing for both E&M and acupuncture services, it is important to ensure that the time spent on each service is documented separately. For example, if you billed for 99213-25, 97810, and 97811, the minimum time for the exam and two sets of acupuncture would be 20 and 23 minutes respectively. This means that you would have spent a minimum of 43 minutes with the patient, leaving 7 minutes for other activities. It is important to document the time spent on each service to ensure proper reimbursement.
Please note: that E&M services do not always require face-to-face interaction. In some cases, the examination can be associated with a review of the patient's file prior to seeing the patient, and the notes can be completed later on the same date, even if the patient is not present. However, regardless of the situation, there is still a small margin for error when it comes to timing.
It is important to clearly document the time spent with the patient during face-to-face interaction and distinguish between time spent on exams or acupuncture. Acupuncture providers tend to spend more time with their patients than other healthcare providers, but proper documentation is necessary for reimbursement by insurance companies.