Acupuncture payment policy Form

Acupuncture Payment Policy

Page 1 of 5 Effective 03/012023

Acupuncture Payment Policy Policy Commercial
Acupuncture is not covered for commercial plan members. MassHealth ACO
• The Plan provides coverage for up to 20 medically necessary acupuncture sessions for the treatment of pain per calendar year without prior authorization. If the member’s condition, treatment, or diagnosis changes, the member may receive additional medically necessary acupuncture sessions for the treatment of pain with prior authorization. o In accordance with MassHealth Physician Manual Program Regulations 130 CMR 433.440, acupuncture services for the treatment of pain may be rendered by − a physician, or
− midlevel practitioner1 who is licensed to practice acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00: The Practice of Acupuncture. o In accordance with MassHealth Community Health Center Manual Program Regulations 130 CMR 405.474, acupuncture services for the treatment of pain may be rendered by: − a physician, or
− acupuncturist licensed to practice acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00: The Practice of Acupuncture. o In accordance with MassHealth Acupuncture Services Manual Program Regulations 130 CMR 447.000, effective for dates of service on or after January 21, 2022, acupuncture services for the treatment of pain may be rendered by an acupuncturist who is licensed to practice acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00: The Practice of Acupuncture. Acupuncture services must address the member’s condition and if no clinical benefit is appreciated after four sessions, then the treatment plan must be re-evaluated. Further acupuncture treatment is not considered medically necessary if the member does not demonstrate meaningful improvement in symptoms. • The Plan covers acupuncture as a substitute for conventional anesthesia in accordance with MassHealth Physician Manual 130 CMR 433.454(E), when provided by an anesthesiologist or certified registered nurse anesthetist (CRNA) licensed to practice acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00: The Practice of Acupuncture. • The Plan covers acupuncture detoxification as defined in 130 CMR 418.02, as described the MassHealth Substance Use Disorder Treatment Manual (130 CMR 418.406(D)(4)) when performed in a substance use disorder outpatient facility licensed by the Massachusetts Department of Public Health in accordance with 105 CMR 164.000: Licensure of Substance Abuse Treatment Programs. Acupuncture detoxification is administered by the Plan’s behavioral health vendor, Beacon Health Options.
Fallon Medicare Plus The Plan covers all types of acupuncture including dry needling2 for the treatment of chronic low back pain effective for dates of service on and after January 21, 2020 in accordance with Medicare NCD 30.3.3 Acupuncture for Chronic Low Back Pain (Version 1).

1 Midlevel practitioner is defined in the MassHealth Physician Manual 130 CMR 433.401.
Midlevel Practitioner – a certified nurse practitioner, certified nurse midwife, certified registered nurse anesthetist, clinical nurse specialist, psychiatric clinical nurse specialist, and physician assistant. 2 Dry needling is reported with CPT code 20560 and/or 20561.

Acupuncture Payment Policy

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Up to 12 visits in 90 days are covered for chronic low back pain is defined as: • lasting 12 weeks or longer; • nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease); • not associated with surgery; and • not associated with pregnancy. An additional 8 sessions will be covered with prior authorization for members demonstrating improvement.
No more than 20 acupuncture treatments are covered annually.
Treatment must be discontinued if the member is not improving or is regressing. Physicians (as defined in 1861(r)(1) of the Social Security Act (the Act) may furnish acupuncture in accordance with applicable state requirements. Physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), and auxiliary personnel may furnish acupuncture if they meet all applicable state 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, • A 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. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, PA or NP/CNS as required by regulations at 42 CFR §§ 410.26 and 410.27.
Acupuncturists are not currently recognized by CMS as Medicare providers, and are not eligible to bill for acupuncture services. Acupuncturists may provide acupuncture as auxiliary personnel “incident to” a physician or qualified nonphysician practitioner service in certain settings. All types of acupuncture including dry needling for any condition other than chronic low back pain are not covered.
NaviCare The Plan covers up to 20 acupuncture sessions per year without prior authorization for any diagnosis including electrical stimulation, infrared and ultrasound services. Additional visits are covered with prior authorization.
Acupuncture detoxification is not limited and is administered by Beacon Health Options. Reimbursement
The Plan reimburses contracted providers for acupuncture services as described in this payment policy.
MassHealth ACO
The Plan reimburses physicians and midlevel practitioners licensed in acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00: The Practice of Acupuncture, for acupuncture services for the treatment of pain when they provide those services directly to plan members in accordance with MassHealth Physician Manual regulations 130 CMR 433.440.3

3 Effective January 21, 2022, amendments to 130 CMR 433.000 eliminate the requirement that physicians supervise licensed acupuncturists rendering medically necessary acupuncture services to MassHealth members. These updates allow physicians and appropriately licensed and credentialed midlevel professionals to bill MassHealth for the acupuncture services that they provide. These amendments correspond to the establishment of new program regulation 130 CMR 447.000: Acupuncture Services, which is also effective January 21, 2022.

Acupuncture Payment Policy

Page 3 of 5 Effective 03/012023

The Plan reimburses anesthesiologists or certified registered nurse anesthetists (CRNAs) licensed to practice acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00 (The Practice of Acupuncture) for acupuncture as a substitute for conventional anesthesia in accordance with MassHealth Physician Manual regulations 130 CMR 433.454(E). Acupuncture detoxification is administered through the Plan’s behavioral health vendor, Beacon Health Options. Claims for acupuncture detoxification for MassHealth ACO members are submitted to Beacon. The Plan reimburses community health centers (CHCs) for acupuncture services for the treatment of pain when a physician or acupuncturist licensed to practice acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00 (The Practice of Acupuncture) provides those services directly to plan members in accordance with 130 CMR 405.474.4 Effective for dates of service on or after January 21, 2022, the Plan reimburses acupuncturists licensed to practice acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00: The Practice of Acupuncture, for acupuncture services for the treatment of pain when they provide those services directly to plan members. Acupuncturists who furnish services to MassHealth members must report the results of these services to the member’s primary care provider in writing. The acupuncturist may report the results of treatment initially by telephone, but he or she must then submit a written report of the initial consultation and subsequent periodic re- evaluations. Fallon Medicare Plus Physicians and qualified nonphysician practitioners (as described in NCD 30.3.3) may submit claims for medically necessary acupuncture services for chronic low back pain, subject to the benefit limits described in NCD 30.3.3.
A physician or qualified nonphysician practitioner (as described in NCD 30.3.3) may bill for acupuncture provided by qualified auxiliary personnel on an “incident to” basis in certain settings in accordance with regulations at 42 CFR §§ 410.26 and 410.27. Coverage of services incident to the professional services of a physician, PA, NP/CNS is limited to situations in which there is direct supervision of auxiliary personnel. Evaluation and management (E/M) services may be reported in addition to acupuncture services by physicians or other qualified healthcare professionals who may report E/M services, using modifier 25 if the patient’s condition requires a significant, separately identifiable E/M sercice above and beyond the usual preservice and postservice work associated with acupuncture services. The time of the E/M is not included in the time of the acupuncture service. NaviCare The acupuncture benefit for NaviCare plan members is administered by American Specialty Health (ASH). Claims for acupuncture for NaviCare plan members are submitted to ASH. Acupuncture detoxification is administered by the Plan’s behavioral health vendor, Beacon Health Options. Claims for acupuncture detoxification for NaviCare members are submitted to Beacon. Referral/Notification/Prior Authorization Requirements MassHealth ACO The Plan provides coverage for up to 20 medically necessary acupuncture sessions for the treatment of pain per calendar year without prior authorization. Additional medically necessary

4 Effective January 21, 2022, amendments to 130 CMR 405.000 eliminate the requirement that physicians supervise licensed acupuncturists rendering medically necessary acupuncture services to MassHealth members. Updates also allow community health centers to bill for services rendered by a licensed acupuncturist, even if a physician does not supervise the provision of these services.

Acupuncture Payment Policy

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acupuncture sessions for the treatment of pain are covered with prior authorization. Submit the prior authorization request and supporting documentation to Fallon Health.
Fallon Medicare Plus
The Plan provides coverage for a total of 12 sessions of medically necessary acupuncture for the treatment of chronic low back pain. An additional 8 sessions are covered with prior authorization for members demonstrating improvement. Submit the prior authorization request and supporting documentation to Fallon Health.
NaviCare The Plan provides coverage for up to 20 sessions of medically necessary acupuncture per calendar year without prior authorization. Additional sessions are covered with prior authorization when medically necessary. Even though the acupuncture benefit for NaviCare members is administered by ASH, requests for prior authorization for additional visits are reviewed by Fallon Health. Submit the prior authorization request and supporting documentation to Fallon Health Care Review.
Summit ElderCare PACE and Fallon Health Weinberg PACE Each PACE plan member is assigned to an Interdisciplinary Team. PACE provides participants with all the care and services covered by Medicare and Medicaid, as approved by the interdisciplinary team, as well as additional medically necessary care and services not covered by Medicare and Medicaid. With the exception of emergency care and out-of-area urgently needed care, all care and services provided to PACE plan members must be approved by the interdisciplinary team. Billing/Coding Guidelines Acupuncture is reported based on 15-minute increments of personal (face-to-face) contact with the patient, not the duration of acupuncture needle(s) placement. If no electrical stimulation is used during a 15-minute increment, report 97810, 97811. If electrical stimulation is used, report 97813, 97814. Electrical stimulation (e.g., 97032) is not reported separately in addition to acupuncture services that include electrical stimulation (97813, and 97814).
Only one initial code may be reported per date of service (97810 or 97813). Use either 97810 or 97813 for the initial 15-minute increment. Needles are inherent to the acupuncture service and are not separately billable. Evaluation and Management (E & M) services (office visits) may be reported by a physician or other qualified nonphysician practitioner (midlevel practitioner) if the member’s condition requires a significant, separately identifiable E & M service beyond the usual preservice and postservice work associated with the acupuncture services (append modifier 25 to the E & M or office visit code). The time of the E & M service is not included in the time for the acupuncture service. Providers whose only licensure is as an acupuncturist may not bill E & M services except as noted below: Note: Acupuncturists eligible to submit claims for acupuncture services provided directly to MassHealth members may bill one office visit (either 99202 or 99212) per member every four weeks. The acupuncturist may bill for both an office visit and acupuncture treatment rendered to a member on the same day in accordance with 130 CMR 447.413 (B). The acupuncture benefit for NaviCare members is administered by ASH. Specific codes and contract terms apply.
Acupuncture Services Code Description

Acupuncture Payment Policy

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97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient 98811 Acupuncture, 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). 97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient. 97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s).

Place of service This policy applies to acupuncture services provided in an outpatient setting. Policy history Origination date:

03/01/2018 Payment Policy Update:
03/01/2022 Connection date & details:
January 2018 – Introduced as a new policy

July 2018 – Clarified billing guidelines.

July 2019 – Annual review, no updates. October 2020 – Added coverage for Fallon Medicare Plus, clarified coding requirements for all products. January 2021 - Clarified Reimbursement and Prior Authorization requirements for acupuncture services for Fallon Medicare Plus, Fallon Medicare Plus Central, Summit ElderCare and Fallon Health Weinberg PACE. January 2022- Clarified payment guidelines for MassHealth ACO.
January 2023 – Updated to reflect changes consistent with MassHealth Transmittal Letter PHY-163 and MassHealth Transmittal Letter ACU-1, effective January 21, 2022.

The criteria listed above apply to Fallon Health plan and its subsidiaries. This payment policy has been developed to provide information regarding general billing, coding, and documentation guidelines for the Plan. Even though this payment policy may indicate that a particular service or supply is considered covered, specific provider contract terms and/or member individual benefit plans may apply and this policy is not a guarantee of payment. The Plan reserves the right to apply this payment policy to all of the Plan companies and subsidiaries. The Plan routinely verifies that charges billed are in accordance with the guidelines stated in this payment policy and are appropriately documented in the medical records. Payments are subject to post-payment audits and retraction of overpayments.