Background
Acupuncture is the selection and manipulation of specific acupuncture points through the insertion of needles or “ needling, ” or other “non-needling ” ways concentrated on these points. The NCD for Acupuncture(30.3), issued in May 1980, states that Medicare payment for acupuncture, as an anesthetic or as an analgesic, or for other remedial purposes, may not be made. Consequently, acupuncture wasn’t considered reasonable and necessary within the meaning of section 1862(a) (1) of the Social Security Act (the Act). In 2004, we considered the use of acupuncture for fibromyalgia and determined that there was no satisfying substantiation for the use of acupuncture for pain relief in cases with fibromyalgia (NCD30.3.1). Also, at that same time, we concluded that there was no satisfying substantiation for the use of acupuncture for pain relief in cases with osteoarthritis (NCD30.3.2).
Claims Processing General Information
- Effective for claims with DOS on or after January 21, 2020, Mackintoshes will fete and pay for acupuncture billing for cLBP services reported with CPT canons 97810, 97811, 97813, 97814, 20560, and 20561 as covered services under NCD30.3.3.
- The applicable ICD- 10 opinion canons are in the attachment to CR 11755 and one of the below CPT canons must be reported for acupuncture for cLBP services. • Mackintoshes will accept claims with the- KX modifier for a fresh 8 services( over and above the original 12 in 90 days) for over to 20 visits in 12 months. By applying the- KX modifier to the claim, the remedy provider is attesting that the fresh services are medically necessary as justified by applicable attestation in the medical record.
Institutional Claims Bill Type and Revenue Coding Information
- Effective for claims with DOS on or after January 21, 2020, Mackintoshes will fete acupuncture for cLBP services reported on institutional claims on types of the bill( TOBs) 012X, 013X, 71X, 77X, and 085X( and profit canons not equal to 096X, 097X, and 098X for Method 1 Critical Access Hospitals( CAHs)).
• Effective for claims with DOS on or after January 21, 2020, Mackintoshes will fete acupuncture for cLBP services reported with profit law 0940 on institutional claims.
- Effective for claims with DOS on or after January 21, 2020, Mackintoshes will fete acupuncture for cLBP services reported on institutional claims on TOB 085X CAH system II with profit canons 096X, 097X, and 098X.
- Mackintoshes will reject/ deny claims with DOS on or after January 21, 2020, that don’t contain the needed CPT and ICD- 10 opinion canons using the following dispatches
- Claim Adjustment Reason law (CARC) 50- These are non-covered services because this isn’t supposed a medical necessity’ by the payer.
- Remittance Advice Remark Code (RARC) M64 – Missing/ deficient/ invalid other opinion.
- Group Code CO (Contractual scores) or PR (Case Responsibility) dependent on liability. In addition to the canons listed over, Mackintoshes will go appeal rights to all denied parties. • Mackintoshes will return to provider/ return as unprocessable claims for acupuncture for cLBP for further than 12 services per annum without the- KX modifier and use these dispatches
- CARC 4- The procedure law is inconsistent with the modifier used or a needed modifier is missing.
Note related to the 835 Healthcare Policy Identification
Segment (circle 2110 Service Payment Information REF), if present
- RARC N657- This should be billed with the applicable law for these services
- Group Code CO
- Mackintoshes will reject/ deny further than 20 acupuncture for cLBP claims per annum using the following dispatches
- CARC 96-Non-covered charge(s). At least one Remark Code must be handed( may be comprised of either the NCPDP Reject Reason( sic) law or Remittance Advice Remark Code that isn’t an ALERT.) Note related to the 835 Healthcare Policy Identification Segment ( circle 2110 Service Payment Information REF), if present
- RARC N640- Exceeds number/ frequency approved allowed within the time period
- Group Code CO Mackintoshes won’t search for acupuncture for cLBP claims with DOS on or after January 21, 2020, but will acclimate claims that you bring to their attention.
In the most recent public content analysis for acupuncture specifically targeted for cLBP, we determined we’ll cover acupuncture for cLBP under section 1862(a) (1) (A) of the Act effective for claims with DOS on and after January 21, 2020. Up to 12 visits in 90 days are covered for cases under the following circumstances For the purpose of this decision, cLBP is defined as - Lasting 12 weeks or longer
- Nonspecific, in that it has no identifiable systemic cause (for illustration not associated with metastatic, seditious, contagious, etc. complaint)
- Not associated with surgery
- Not associated with gestation We’ll cover a fresh 8 sessions for those cases demonstrating an enhancement. No further than 20 acupuncture treatments may be administered annually.
- Not associated with gestation We’ll cover a fresh 8 sessions for those cases demonstrating an enhancement. No further than 20 acupuncture treatments may be administered annually.
- RARC N640- Exceeds number/ frequency approved allowed within the time period
- Mackintoshes will reject/ deny claims with DOS on or after January 21, 2020, that don’t contain the needed CPT and ICD- 10 opinion canons using the following dispatches
- Claim Adjustment Reason law (CARC) 50- These are non-covered services because this isn’t supposed a medical necessity’ by the payer.
- Remittance Advice Remark Code (RARC) M64 – Missing/ deficient/ invalid other opinion.
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