Billing and Coding Loss of Payment
I want to talk to you a little bit about Billing and Coding Loss of Payment and whatâs been going on and Iâm sure many of you have noticed on whatâs called the medically unlikely edits or the limits to care. And Iâm sure some of you have seen it.
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Disclaimer:Â The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.Â Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Hi everyone. This is Samuel Collins, the coding and billing expert for acupuncture and the American Acupuncture Council. But most importantly, the coding and billing expert for you. While I do have roles with the world health organization, United healthcare and Optum health. My ultimate goal is for the practitioners just as American Acupuncture Council is, and this is another addition to make sure that youâre getting things right, understanding whatâs going on, promoting your practice. And I do the billing side Iâm with the American Acupuncture Council Network, which means weâre part of the malpractice side that really helps you with the coding, the billing, the education and seminars weâre here today. I want to talk to you a little bit about whatâs been going on and Iâm sure many of you have noticed on whatâs called the medically unlikely edits or the limits to care. And Iâm sure some of you have seen it.
Hey, why are they denying? In fact, weâre running into some areas in New York where theyâre paying only for one, which actually shouldnât be whatâs there others paying for two or three? Well, what is correct? What do we have to make sure weâre doing to make sure we are getting paid fully, but also making sure if they donât pay us, what do we do about it? And where does it come from? So letâs go to the slide. So you can start to take a look at whatâs happening. So in these slides, youâll notice I have here. It says acupuncture, medically unlikely edits. MUE is what they term it. And what that deals with is the maximum number of services that can be done per day. And thatâs not just for acupuncture acts. So that includes physical medicine and other services. And also want to hit a little bit on to medical necessity, cause thatâs really kind of where this dovetails.
So if you take a look here and I know this is smallest, let me enlarge this a little bit for you. Youâll notice here. This is from empire blue, cross blue shield. And notice what theyâre bringing to this doctorate says the review indicated your average utilization of acupuncture sessions of one hour or greater personal one-on-one contact with a patient is higher than expected. So that means youâre doing an hour more so than everyone else. Theyâre not saying necessarily itâs wrong, but because itâs above average, theyâre trying to figure out why. So notice in the next paragraph I highlighted it says, we are aware of many factors that may impact the coding of your acupuncture services. Our goal is to assist providers. So theyâre not necessarily trying to be punitive, but trying to figure out why are you doing more is for too much, not necessarily, if you talk to most acupuncturist and Iâve taught seminars now for 23 years.
And I would say the average acupuncture is probably does between two and three sets regularly. So four is not unheard of, but itâs not typical, but I would say the average is two or three. So when it goes to four on a very regular basis, there could be some issues. In fact, this is probably where the medically unlikely edits come from. Well, letâs talk about it from a medical necessity standpoint, if youâre going to do ortho, thatâs why thatâs part of what we have to determine. So Iâm going to give you what medical necessity is determined by the company, American specialty health, which Iâm sure a lot of you have a tendency to. Thereâs kind of a love, hate relationship with them. I donât think the hate is so much from the protocols is just, I wish they paid more, but ultimately I do think they make a nice protocol for what they determine as medical necessity.
So always understand when youâre going to do four sets or more, the Y has got to be based on the diagnosis. The severity of the problem. Now the difficulty with diagnosis is often the diagnosis for acupuncture is simply just pain. So how does that really demonstrate severity unless youâre coding like a lumbar disc. It really doesnât. So remember your chart notes are going to be an important factor. The past medical history of the history, including is it traumatic? Is it repetitive? Is it acute? In other words, severity, whatâs also going to be part of that though, is comorbid factors. Things that can complicate the patient, things that are underlying patients, very overweight patient has a very poor diet. Patient is diabetic. While you may not be treating those things directly, could they affect how the patient responds? Meaning why did I do four sets, other things?
They look at our range of motion, palpatory findings, orthopedic testing, neurologic testing, but they also do look at the tongue and pulse notice all these say quantify. Cause we want to know, well, if itâs severe, these things would all be more severe as evidence and quantified do. Remember they will look at the functional limitation, how the patient is getting better or not better just stating the patient feels better is not going to be enough. We have to be, how is it better? What can they do now that they couldnât do before? And thereâs always going to be goals for it. So ultimately think of medical necessity as kind of looking at how you would see a patient overall in their improvement, not just paying level. And thereâs something to think of. This is from a company called health partners and I liked the way they put together the factors that they look at for medical necessity, things they put in mind.
Notice the first thing, gender fatigue, lack of energy, notice mobility, agility, strength, sleep issues, not falling asleep. You know, not waking up feeling rested or just the decreased quality of life. Those are factors that if you quantify given issue of potential severity beyond just stating pain, now I bring this up because of course, if youâre going to do acupuncture, we know that thereâs four codes and you know that the four codes are there to allow us to build additional services when necessary. Some patients may get one, two, three, or four, but whatâs important to remember is that acupuncture requires two things for billing purposes, for billing purposes, or as I like to call it, Billing and Coding Loss of Payment, youâll notice the acupuncture code says one or more needles, which means you have to insert a needle. But then it also says initial 15 minutes and each subsequent code says the same thing. It says reinsertion, which really should be additional insertion and 15 minutes.
So the codes are really going to be based on inserting needles and spending time. So if youâre telling me that youâve done four sets, that means you actually have to be in the room with the patient for the full fifth, 60 minutes or close to it and do four distinct insertions one in the first 15, second, 15 and so on, which is not something that you wouldnât do, but you have to document it and letâs remember, and see here. It says how the 15 minute session is defined. Remember, as soon as you walk in the room with the patient, say, Hey, how are you feeling today? The time starts, all the things you do. Thatâs part of your acupuncture, including review of history. Hand-washing choosing points. All of that counts. Whatâs important is to document it because youâre doing multiple sets. The one issue weâve run in through the American acupuncture council is offices.
Arenât documenting that well. So that becomes a problem. Well, itâs also a problem just based on number. So letâs take a look here and Iâll show you. This is an example of a soap note for acupuncture that has documented three sets. And I want you to see here, and I donât want you to really comment about necessity. Just show how it works. Notice each set is identified set one, two and three. Notice the points are identified in addition, the face-to-face time from and two, or it could be minutes and then retention. So clearly when you see here, youâre noticing there is clearly three sets because thereâs three separate insertions as documented notice the face-to-face time equals hitting the eight minute rule, if you will. And then it shows the separate retention. Remember donât count retention towards the total time. So if youâre doing multiple sets, we have to make sure that weâre documenting all those factors. Because if weâre doing two, three or four, it still has to be shown. Did we do it? Well, this brings me to this kind of medically unlikely edits or what CPT does is they do edits for all types of codes. And thereâs two types of edits that are common.
The first one is called the correct coding initiative at it. Yeah,
That is one that the correct coding initiative edit is one that there we go is used for coding, such for chiropractors, like a chiropractor. When theyÂ Do manipulation, there are codes that are part of manipulationÂ That have to be separately coded. So by example, they Have to not code nine 71, four zeroÂ With manipulation. This I apologize. My phone is,
But you have someone who keeps trying to call through. So I apologizeÂ That these coding initiatives, goodness, here we go. And my apologies for this, IÂ Cannot seem to get someone to understand what a message says. Iâm not available. That Iâm notÂ Nonetheless, they kept trying letâs do this.
Okay. My falsies bear with me, correct coding initiatives. Just tell me what codes can and cannot be billed together. Okay? So for chiropractors, thatâs common for recordÂ Puncture. Itâs not, but weâre acupuncture does help.
Some common issues. Common issues for acupuncturists are under something called theÂ Medically unlikely edits.
Medically unlikely deal with codes that can not be coded for an excess amount of units. Now you may think, what does that mean? This is where it comes in. Youâve noticed where theyâre saying acupuncture can only be billed for say three sets or two sets depending on who youâre dealing with. Thatâs what theyâre referring to. So what are you Louise there for any CPT code that the maximum amount of services that will be provided under one visit or a date of service, this applies to all types of codes. So by example, to show you where itâs also applies, itâs not just for acupuncture. Things like modalities have one, some have four. If itâs an attempt to Allie, when itâs timed such as notice the here itâs just the unattended services or one notice the codes for electric STEM allow for, but then ultrasound is only two. And again, thatâs just based on these edits that say thatâs the maximum per visit weâll procedures. Get a little bit different. Notice for exercise nine, seven one one zero. It is six
For neuromuscular education. It is, it is for
Because itâs a little different service than exercise. So theyâre limiting to four notice massage only four. Now you may say who comes up with these itâs part of the coding committees edits that do such. So make sure that youâre using the correct codes and amount of units. Now I doubt many of you go well above that notice manual therapy says six. So these are what theyâre going to indicate as the amount that you can do maximum per day. So if you did more than six, theyâre going to say no. Well, where does our services fit? You can see here therapeutic activities, by the way, I chose these codes here on the right side specifically because thatâs the limits for those codes. But also those are the codes. If youâre billing VA patients, those are the services that the VA will automatically authorize for acupuncture providers.
But hereâs what weâre running into. As I mentioned, the VA, take a look here. Hereâs whatâs called the standard episode of care SEOC and youâll notice it says for acupuncture 12 visits, but notice it says a maximum of one additional unit of acupuncture with, or without electric STEM when reinsertion of needles. So under this one, and this is an Optum health, when theyâre saying, Hey, you can only do two. And Iâm sure many of you have run into that. Whereas before you could do four or five, itâs just saying theyâre allowing only two. So thatâs OptumHealth now again, that goes against what the normal edit says, because notice this one from tri West and youâll see, this is really just from December. I know you canât see the date, but youâll notice here. It says the maximum unit
Acupuncture. And youâll notice the map
Maximum units for acupuncture indicate nine, seven, eight one zero. The first set is one unit, but then the additional sets notice are two. So notice theyâre indicating under this correct coding under the many medically unlikely edits. The limit is three, meaning one initial set and up to two additional sets. Now to give you a little history of that, that hasnât always been the case. I want you to see here. This comes directly from United healthcare, and this is dated notice 2018 through 19. And it was different. It says the medically unlikely edits indicated that you can do one initial set, but then three additional sets of manual. And then electoral was one and two only. So three total. So at that time it was four, but letâs fast forward to this year. Youâll notice again, this is the health care notice from 2020. And now itâs indicating that according to this edit notice here, it says the policy enforces the code description for acupuncture services, which are to be reported based on 15 minute time increments, personal face-to-face time.
And itâs indicating in accordance here nine, seven, eight one zero is one. By the way, one makes sense. You can only have one initial set, but then notice instead of it being three, it is now two. So thatâs also two here. So what is the new rule for medically unlikely edits for acupuncture is three. Now what if you say Sam, I need to do more now. Medically unlikely doesnât mean an absolute, could you defend doing more and request more? Sure, but now youâd have to show the medical necessity of what did my fourth set do that wasnât completed within the first three sets? I think thereâs some things that can be disputed there, particularly if youâre doing front and backside sets multiple diagnosis, but again, youâd have to kind of come up with what is the fourth set doing that the others arenât simple answer.
If you build three, you should not have much problem, but weâre seeing issues here. This is a United healthcare, and youâll notice on this visit, theyâre paying the one initial set theyâre allowing it, but then notice this one theyâve taken out. It used this code in three, six, two. So what does [inaudible] mean? Well, letâs look at this full EOB notice in three, six, two says the number of days or units exceeds our acceptable maximum. So letâs take a look at what there are allowing notice on this one, visit on 10 27, theyâre allowing the initial set, theyâre paying the full amount or allowing it, but then on the additional sets they allow the nine seven eight one one four one and nine, seven eight, um, one, one again, but then not allowing the third set or the third or four set, which would be the nine, seven eight one three.
Now, even this one here, what Iâm trying to point out is that theyâre beginning to say, Hey, weâre not going to pay more than three if you bill such. So you want to make sure that if youâre billing more than three chances are with some payers. And I will tell you anthems Cigna, Aetna, as well as United have begun to really follow this as well as the VA. So what do we need to do to make sure weâre getting paid properly is to make sure weâre number one, sticking within the three. And if weâre going to go more than three, weâre going to have to send explanation, but hereâs one of the problems weâve run into. There are some plans, even like this one that theyâre not paying that third. So when that happens, whatâs going on. Hereâs another one and this is an empire or excuse me, a Cigna, excuse me.
And Iâm just going to blow this up so you can see here. It indicates the number of units built for this service exceeds the limit for the day. Now, if you look at this bill though, theyâre allowing the first set and the second set, but not allowing the third. So then wait a minute. Why are they not allowing that amount or excuse me, they are allowing that amount. I want to share this one is doing three. So thereâs one initial one, follow one follow. But then the fourth is saying no. And that comes from those edits. If you were billing, or as I like to call it, Billing and Coding Loss of Payment, more than three, youâre very likely to be denied for the fourth. Some payers may allow, but most are going to follow these edits. But what if youâre running into an issue with it where youâve billed only three and theyâve denied it, then Iâm going to push back.
Hereâs a letter. And you know, youâre welcome to kind of see how it does. It just brings up the points of Iâve recently received a claim for payment that was denied due to the medically unlikely edits. And youâre going to bring up the medically unlikely edits indicate that there should be three. So if theyâre only paying for two, this is the response. You have to say, the medically unlikely edits indicate three, unless you have a contract otherwise. And Iâve seen a lot of plans doing this. And I think whatâs occurred is a lot of them have misinterpreted the edits and somehow are allowing to, so you want to make a little bit of a pushback. In addition, for those of you who are billing Optum, when youâre billing, Optum, meaning VA, and theyâre only allowing two, hereâs my concern. How is the Western part of the country try West allowing three and the Eastern part of the country only allowing two yet.
Itâs the same, the same benefit. And of course itâs because Optum has misinterpreted it and there should be three. So this is a little bit of the pushback. Is this something Iâm very excited about? No, I donât like to see any limitations, but we have to know what weâre working with now. The good news is three sets is pretty typical that most arenât going even that high. In fact, Iâve taught seminars now for 20 years. And I would say on average, when I asked the room, how many people are doing four sets, itâs a very minor percentage. But when I ask whoâs doing two or three, itâs most so again, if youâre sticking within two or three, this may not make much of an effect, but if youâre doing four, a Canon may want to rethink of whatâs going on. Now you can see, this is what Iâm here to do is help you understand it, help you fight back with it.
And Iâm going to say, give me a chance to help you do that. The American Acupuncture Council is your resource for these courses, but also Iâm a resource. Allow me to be part of your office, take your phone out, take your camera and just put it over that code. And what thatâs going to do is give you an opportunity to hire me for your office, but weâre going to give you the first 30 days for no charge. Give me a trial. Let me help you with a claim. Let me help you show whatâs going on. Realize these rules and codes. We have fight back letters and all types of things that we can do that I can aid you and making sure youâre being properly paid and not having something where your claims are constantly being denied. Think of how many times youâve had denials for ENM codes or other services that were not correct.
What do you do about it? Iâm going to give you the rules and the laws, not opinions to fix it. The American Acupuncture Council is your resource. Allow me to be part of your office. You can join for as little as $25 a month, or you can do it with seminars. So Iâm going to say, take a look at the services we offer Iâll guarantee youâll get help. In addition, take a look on our site when get there. Iâve got videos and things of other things that we have done and looking at our news section for updates, we are here to help and I want to make sure today you understand what do I deal with and how do I deal with medically unlikely edits? What do they mean if I can do three great, but what if theyâre cutting me less than three? But what if I do four?
How do I fight back for that? So thatâs what weâre here to do is to help you for that. So Iâm going to wish you well and say, stay tuned next week. The, um, host will be Jeffrey Grossman, and Iâll see you next time. I hope I become part of your office. Take a look at our site, take a look at the services we offer. Weâre here to make your office successful. Donât guess letâs make sure youâre getting paid. We do much more than just simply tell you a code. We make sure youâre doing it right. Thank you everyone.
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